Every finding on record at Covered Bridge Health Campus

Based on interview and record review, the facility failed to notify the Ombudsman that residents were discharged from the facility for 3 of 3 discharged residents' records reviewed. (Residents 63, 64, and 65) Findings include:1. The clinical record for Resident 63 was reviewed on [DATE] at 11:53 A.M. The resident was admitted to the facility on [DATE]. A Progress Note, dated [DATE] at 6:07 A.M., indicated the resident experienced a change of condition and was sent to the local hospital's emergency department for evaluation.A Progress Note, dated [DATE] at 5:21 P.M., indicated the resident was admitted to the hospital. The Census section of the resident's Electronic Health Record (EHR) indicated the resident was discharged from the facility on [DATE] and the resident was not anticipated to return. The Discharge Report sent to the Ombudsman for [DATE] was provided by the Director of Nursing (DON) on [DATE] at 11:44 A.M. The report did not include Resident 63.2. The clinical record for Resident 64 was reviewed on [DATE] at 1:51 P.M. The resident was admitted to the facility on [DATE]. The resident was receiving treatment for a worsening respiratory infection in [DATE].A Progress Note, dated [DATE] at 05:21 P.M., indicated the resident's health had been declining and he passed away early that afternoon. The Census section of the resident's EHR indicated he expired on [DATE].The Discharge Report sent to the Ombudsman for [DATE] was provided by the DON on [DATE] at 11:44 A.M. The report did not include Resident 64.3. The clinical record for Resident 65 was reviewed on [DATE] at 11:22 A.M. The resident was admitted to the facility on [DATE] with plans to return to the community.A Progress Note, dated [DATE] at 11:53 A.M., indicated the resident's family arrived to take him to an Assisted Living Facility. The Census section of the resident's EHR indicated the resident was discharged from the facility on [DATE] and was not anticipated to return. During an interview, on [DATE] at 1:48 P.M., the Social Services Director (SSD) indicated she sent a report to the Ombudsman each month listing the residents that discharged from the facility. She included residents that discharged and were expected to return to the facility, residents that were at the hospital, residents that left the facility against medical advice, and residents that had received a 30-day involuntary discharge notice. She based the Ombudsman notification off a report she ran each month.The Discharge Report sent to the Ombudsman for [DATE] was provided by the DON on [DATE] at 11:44 A.M. The report did not include Resident 65.During an interview, on [DATE] at 11:28 A.M., the SSD indicated she had not been including residents that were discharged and not expected to return to the facility or expired residents on the report she sent to the Ombudsman each month.The current facility policy, titled Ombudsman Notification, dated [DATE], was provided by the DON on [DATE] at 3:05 P.M. The policy indicated, .Federal regulation F628 requires that the facility sends a copy of the Notice of Transfer/Discharge to a representative of the Office of the State Long-Term Care Ombudsman. This includes voluntary and involuntary discharges and transfers.The Director of Social Services, or designee, will send a copy of the discharge census report to the Office of the State Long-Term Care Ombudsman monthly or at least 30 days prior to issuing the involuntary discharge notice.complete the Ombudsman Notification Observation in the electronic health record as evidence that the notice was sent.Exceptions to the monthly ombudsman notification requirement apply with the transfer or discharge is due to the following.resident's health improves sufficiently to allow a more immediate transfer or discharge.An immediate transfer or discharge is required by the resident's urgent medical needs.If an immediate discharge due to the above reasons occurs, the Director of Social Services.will inform the .Ombudsman within 24 hours.3.1-12(a)(6)(A)(iv)

Based on observation and interview, the facility failed to follow manufacturers guidelines related to priming an insulin pen for 1 of 2 insulin pens observed. (Resident 55)Findings include: Medication administration was observed on 02/11/2026 at 11:03 A.M., with Qualified Medication Aide (QMA) 5. The QMA prepared insulin for Resident 55 using an insulin pen and indicated the resident was to receive 3 units of lispro (Humalog) insulin per the sliding scale. The QMA removed the insulin pen from the medication cart, checked the label, removed the pen cap, cleaned the end of the pen with an alcohol wipe, applied the needle, and removed the cap of the needle. She turned the pen dose selector to two units, primed the pen holding the pen tip facing parallel to the floor, squirted out the two units of insulin, turned the pen dose selector to 3 units, donned gloves, and went into the resident's room. The QMA administered the insulin into the resident's abdomen. During an interview, with QMA 5, immediately following the procedure, she indicated she was not trained on how to hold the pen when priming it. The Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) for Resident 55 was reviewed on 02/11/2026 at 2:26 P.M. The record indicated the resident had no critical blood sugar values prior to 02/11/2026. The package insert for the lispro insulin pen was provided by the Assistant Director of Nursing (ADON) on 02/11/26 at 11:30 A.M. The instructions for use indicated, .Priming your Humalog .Pen .Turn the dose knob to select 2 units .Hold the Pen with the needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top .Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows0 .A drop of insulin should be seen at the needle tip .3.1-37(a)3.1-47(a)(1)

Based on record review and interview, that facility failed to follow a physician's order related to a blood thinning medication administration for 1 of 6 residents reviewed for unnecessary medications. (Resident 20)Findings include:The clinical record for Resident 20 was reviewed on 02/09/2026 at 11:46 A.M. An admission Minimum Data Set (MDS) assessment, dated 01/09/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hip and knee replacement and deep vein thrombosis (blood clot - DVT). A Hospital Discharge summary, dated [DATE], indicated the resident had a total right hip replacement on 12/30/2025. The resident was to be given Lovenox (blood thinning medication) 40 milligrams (mg) once a day until the resident's INR (International Normalized Ratio, a standardized blood test result that measures how long it takes for your blood to clot) level was greater than 2.0. The resident had problems with deep vein thrombosis. The resident's next INR level was to be drawn on 01/05/2026. The resident's last INR was drawn on 12/12/2025. The resident's January 2026 Electronic Medication Administration Record indicated the resident had not received the Lovenox medication on 01/04/2026 due to the medication was on hold and on 01/05/2026 because the medication was discontinued. The clinical record lacked documentation that the physician was notified of the resident's Lovenox medication being held on 01/04/2026. The clinical record lacked documentation that the Lovenox order was clarified with the physician prior to 01/05/2026.During an interview, on 02/10/2026 at 11:24 A.M., RN 2 indicated when a resident was admitted from the hospital, she would get report from the hospital nurse and put the resident's information in the facility computer system. She would transcribe the hospital discharge orders into the computer, and a second nurse would verify the medications. She would fax all the paperwork to the resident's physician and let them know the resident admitted to the facility.During an interview, on 02/10/2026 at 12:52 P.M., the Director of Nursing (DON) indicated the facility staff should transcribe the orders per the resident's hospital discharge records. During an interview, on 02/11/2026 at 11:24 A.M., the DON indicated the resident didn't get the Lovenox when she came because they were putting her at risk by giving her the Lovenox based on the INR documented in the hospital record, even though that INR level was obtained prior to the resident's surgery date. That was why they clarified the order on 01/05/2026. During an interview, on 02/11/2026 at 11:45 P.M., Nurse Practitioner 3 indicated when a resident was admitted to the facility she would have to see them within three business days. The facility should follow the orders the resident was discharged with from the hospital, she would typically make changes on her first visit with the resident if she needed to. She remembered the facility asking about the resident being on Lovenox and Coumadin (a blood thinning medication) at the same time. She explained to them that the Coumadin was not immediately effective and it took time to reach the therapeutic level, so the hospital had put the resident on on Lovenox at the same time with Coumadin. The facility should have given the Lovenox medication when the resident first came from the hospital. The current facility policy titled Medication Error Reporting with a review date of 12/17/2024, was provided by the DON on 02/11/2026 at 10:46 A.M. The policy indicated, .To identify medications given in error and expedite correction actions.3.1-48(c)(2)

Based on observation and interview, the facility failed to appropriately store medications for 1 of 3 medication carts reviewed. (100 Hall Medication Cart)Findings include: On 02/09/2026 at 10:57 A.M., the 100 Hall Medication Cart was observed with RN 4 and contained the following:- A small round white pill was lying loose in the bottom of the second drawer along with dust and paper debris and- A half of a small oval green pill was lying loose in the bottom of the third drawer along with dust and paper debris.During an interview, on 02/09/2026 at 10:58 A.M., RN 4 indicated she didn't know what the pills were or who they belonged to, pills should not be loose in the medication cart. The current facility policy, titled Medication Storage dated 11/01/2022, was provided by the Director of Nursing (DON) on 02/12/2026 at 11:50 A.M. The policy indicated, .Medications must be stored under proper conditions to protect against degradation .3.1-25(o)

Based on record review and interview, the facility failed to transcribe a physician order on admission for 1 of 16 resident records reviewed. (Resident 20)Findings include:The clinical record for Resident 20 was reviewed on 02/09/2026 at 11:46 A.M. An admission Minimum Data Set (MDS) assessment, dated 01/09/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hip and knee replacement, hypertension, osteoporosis, malnutrition.A hospital discharge record, dated 01/27/2026, indicated the resident was to receive Coumadin (a blood thinning medication) 3 milligrams (mg) on Sunday, Monday, Wednesday, and Friday. An physician's order, with a start date of 01/27/2026, indicated the resident was to receive Coumadin 3 mg once a day on Monday, Wednesday, and Friday. During an interview, on 02/10/2026 at 11:24 A.M., RN 2 indicated when a resident was admitted from the hospital she would get report from the hospital, put the resident in the facility computer system, assess the resident, get their vital signs, and transcribe the orders into the system, and a second nurse would verify the medications. She would fax all the paperwork to the resident's physician and let them know they admitted to the facility.During an interview, on 02/10/2026 at 12:52 P.M., the Director of Nursing (DON) indicated the facility staff should transcribe the orders per the resident's hospital discharge records.During an interview, on 02/11/2026 at 11:24 A.M., the DON indicated when the resident came back from the hospital the physician's order should have been transcribed for her to receive the Coumadin on Sunday, Monday, Wednesday, and Friday and not Monday, Wednesday, and Friday. The physician changed the order on 01/30/2026. The current facility policy titled, Guidelines for Medication Orders with a review date of 12/12/2025, was provided by the DON on 02/11/2025 at 10:46 A.M. The policy indicated, .To establish uniform guidelines in the receiving and recording of medication orders.Medication orders.when recording medications orders specify: The type, route, dosage, frequency, strength of the medication.3.1-50(a)(2)

Based on record review, observation, and interview, the facility failed to ensure fall preventative devise interventions were in place as ordered for 1 of 3 residents reviewed for accident hazards. (Resident 27) Findings include: The clinical record for Resident 27 was reviewed on 01/21/25 at 9:23 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/13/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, hypertension, and malnutrition. A Fall Care Plan, with a start date of 07/12/24 and a revised date of 01/23/25, included but was not limited to, the following intervention: Highlighter tape to wheelchair brakes with a start date of 09/08/24. A Progress Note, dated 09/09/24 at 4:02 A.M., indicated the resident had a fall while trying to transfer herself into her wheelchair to go to the bathroom. The left side wheelchair brake was not locked upon inspection. The resident had no injuries. An Interdisciplinary Team (IDT) Note, dated 09/09/24 at 1:36 P.M., indicated the immediate intervention to prevent further falls was to apply highlighter tape to the resident's wheelchair brake handles. A Progress Note, dated 12/16/24 at 9:00 A.M., indicated the nurse walked into the resident's room to administer her medications. When the resident went to sit in her wheelchair, she had forgotten to lock her brakes and the chair rolled out from underneath her. During an observation on 01/21/25 at 9:07 A.M., Resident 27 was sitting in her wheelchair in her room. Her call light was in reach. Her wheelchair brakes lacked any highlighter tape to them. During an observation on 01/21/25 at 2:31 P.M., Resident 27 was sitting in the common area using a cell phone. There was no highlighter tape to the resident's wheelchair brakes. During an observation and interview on 01/21/24 at 2:54 P.M., the Director of Nursing (DON) indicated after a resident had a fall they would be assessed by a nurse and the nurse would complete the appropriate paperwork. The management staff would review the fall and would try to determine a root cause of the fall. They would then determine an appropriate intervention for the fall. The Care Plan would be updated. If there was a need to alter the resident's environment, then the nurse working the floor or the IDT would make those changes. The resident should have had highlighter tape to the wheelchair brakes if she was care planned for it. The resident was sitting in the common area with no highlighter tape to the wheelchair brakes. The current facility policy titled, Fall Management Program Guidelines, with a review date of 12/17/24, was provided by the DON on 01/22/25 at 12:06 P.M. The policy indicated, .to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures .Nursing staff will monitor and document continued resident response and effectiveness of intervention for 72 hours . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to have a medication error rate of less than 5% for 2 of 32 medication administrations observed. (Resident 3) Findings include: During an observation on 01/22/25 at 9:36 A.M., RN 6 prepared Resident's 3 morning medications. She placed all of Resident 3's morning prescribed (14) different medications in one medication cup. The resident's morning dose of Buprenorphine, 2 mg, was to be administered by sublingual (placing a drug under the tongue to dissolve and be absorbed directly into the bloodstream) administration. The RN retrieved the resident's prescribed eye drops, refresh tears and brimonidine, from the medication cart. The nurse took the prepared cup of medications, and the two types eye drops to the therapy gym where the resident requested to take the medications. The resident was given the cup of medications and took them whole with sips of her drink. The nurse then administered the eyes drops to the resident, one after the other, with no wait time in between. The resident's Buprenorphine was not administered by the prescribed sublingual route and all eye drops were administered with no delay in time. During an interview on 01/22/25 at 10:13 A.M., RN 6 indicated if a resident's medication was ordered sublingually, then it should be placed under their tongue. She should have told the resident the medication was sublingual, and explained it to the resident. She should have waited 5 to 10 minutes between administering the two eye drop medications. The clinical record for Resident 3 was reviewed on 01/22/25 at 10:05 A.M. An Annual Minimum Data Set (MDS) assessment, dated 08/23/24, indicated the resident was cognitively intact. The current, open-ended physician's order, with a start date of 08/25/24, indicated the staff were to administer buprenorphine (a pain medication), sublingually, once a day. The current, open-ended physician's order, with a start date of 12/10/24, indicated the staff were to administer brimonidine (an eye drop), one drop in each eye, twice a day. The current, open-ended physician's order, with a start date of 08/18/24, indicated the staff were to administer refresh tears (an eye drop), one drop in each eye, three times a day. The current facility policy titled, General Guidelines for Administration of Medications, with an effective date of 12/01/22 and was provided by the Administrator on 01/22/25 at 10:31 A.M. The policy indicated, .When administering a medication, the following steps should be followed: a. Check the physician's order to verify dosage specifics. b. Make note of the [five rights], to assure the proper administration of medication .right route of administration . The current facility policy titled, Eye Drop Administration, with a revised date of 11/2018, was provided by the Director of Nursing on 01/22/25 at 12:06 P.M. The policy indicated, .If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 10 minutes, then repeat . 3.1-25(b)(9)

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to urinary catheter care for 2 of 3 residents reviewed for infection control. (Residents 10 and 15) Findings include: 1. On 01/16/25 at 1:40 P.M., Resident 10 was observed in her room sitting in a recliner. The resident's urinary catheter drainage bag was hanging from a pocket on the recliner, with two inches of the bottom of the bag resting on the floor. On 01/16/25 at 3:29 P.M., the resident was observed in her room sitting in the recliner. The resident's catheter drainage bag was hanging from the chair with two inches of the bottom of the bag resting on the floor. On 01/17/25 at 1:43 P.M., the resident was observed in bed. The bed was in a low position and the catheter bag was hanging on the left side of the bed. An inch of the bag was resting on the floor. Qualified Medication Aide (QMA) 2 observed the bag and indicated it shouldn't be touching the floor; it was probably because the bed was so low. She indicated she would adjust the position of the bag. On 01/22/25 at 10:34 A.M., the resident was observed in her recliner. The resident's catheter drainage bag was hanging from the side of the chair, with at least two inches of the bottom of the bag resting on the floor. Certified Nurse Aide (CNA) 4 observed the bag and indicated it shouldn't be touching the floor. During an observation on 01/22/25 at 10:41 A.M., CNA 3 and CNA 4 entered the resident's room to provide catheter care. The resident was sitting in her recliner. The resident was in Enhanced Barrier Precautions (EBP) and staff were to wear a gown and gloves when they provided catheter care. The CNAs donned gowns, entered the resident's room, washed their hands, and donned gloves. CNA 3 brought supplies from the bathroom to the resident's bedside, moved items from the nightstand, and then placed the supplies on the nightstand. CNA 3 then went to the other side of the resident's bed, pulled the string to shut the blinds, pulled the cord to turn on the light above the resident's bed, and used the bed remote to adjust the position of the bed. CNA 3 and CNA 4 went over to the resident in her chair. CNA 3 picked up the catheter drainage bag that was laying on the end of the recliner, removed a blanket from the resident, and then, with CNA 4's assistance, helped the resident move from the chair to the bed. CNA 3 hung the drainage bag on the side of the bed. The CNAs got the resident into a laying position, pulled the resident's pants down, and opened the resident's brief. CNA 3, wearing the same gloves, removed a wet washcloth from the basin, applied cleanser to the washcloth, and began cleansing the resident. CNA 3 washed, rinsed, and dried the resident's perineal area, then cleansed the urinary catheter tubing. During an interview on 01/22/25 at 10:56 A.M., CNA 3 indicated she should have removed her gloves, washed her hands, and put on new gloves before she provided perineal/catheter care. The resident's clinical record was reviewed on 01/17/25 at 1:54 P.M. An Admission Minimum Data Set (MDS) assessment, dated 11/11/24, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, stroke, malnutrition, and neurogenic bladder. The resident had an indwelling urinary catheter. 34232 2. During an interview and observation on 01/15/25 at 1:16 P.M., Resident 15 indicated he had an indwelling urinary catheter because he had trouble emptying his bladder. The catheter tubing was visible and contained cloudy yellow urine. Catheter care for Resident 15 was observed on 01/22/25 at 9:59 A.M., with CNA 4. The CNA donned a gown and gloves from an isolation cart located in the hallway outside of the resident's room, entered the room, went into the bathroom, and prepared pan of warm water, using her gloved hands to turn the water on and off. The CNA proceeded to close the window blind, pull the privacy curtain, then clean the resident's suprapubic catheter tubing that extended out of the resident's abdomen. The CNA failed to changer her gloves after touching items and before starting the procedure. The resident's clinical record was reviewed on 01/21/25 at 2:20 P.M. A Quarterly MDS assessment, dated 11/14/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure and obstructive uropathy. The resident had not had a Urinary Tract Infection (UTI) in the previous 30 days. The resident had an indwelling catheter and was always continent of bowel. During an interview on 01/22/25 at 1:49 P.M., the DON indicated the resident was admitted to the facility with the suprapubic urinary catheter. The resident had the catheter placed due to retention issues. He just recently had a stent placed to help with the retention. He was on an antibiotic prophylactically (as a preventative measure) following the procedure. The current Urinary Catheter Care policy, with a reviewed date of 12/16/24, was provided by the DON on 01/22/25 at 12:06 P.M. The policy indicated, .To prevent infection of the resident's urinary tract .Be sure the catheter tubing and drainage bag are kept off the floor .Prior to beginning the procedure .Close the room entrance door .Pull the privacy curtain .Close drapes .close blinds .Wash and dry hands thoroughly .Put on gloves .Wash the resident's genitalia and perineum thoroughly .Place soiled linen into designated container .Remove gloves and discard .Wash and dry your hands thoroughly .Put on clean gloves . 3.1-18(l)

Based on observation, interview, and record review, the facility failed to follow the physician's orders related to the treatment for a pressure ulcer for 1 of 2 residents reviewed for pressure ulcer treatments. (Resident 47) Findings include: During an observation on 01/21/25 at 11:06 A.M., Resident 47's dressing change was observed. The resident's pressure wound, located on her right upper buttock, was observed with the Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) Coordinator. The ADON and MDS Coordinator donned gowns and gloves prior to entering the resident's room. The ADON indicated the current treatment was to cleanse the wound with wound cleanser, apply collagen powder, then Anasept gel (an antimicrobial), and cover the wound with a border dressing. The staff members entered the room, raised the bed, pulled the covers back, pulled the resident's brief down, then rolled the resident to her left side. The resident's wound was uncovered and open to air. The ADON removed her gloves and washed her hands. The wound was quarter sized and had a dark red wound bed with a measurable depth. The ADON donned clean gloves, cleansed the wound using a spray bottle of cleanser, patted the wound dry with gauze, applied collagen powder to the wound bed using a sterile swab, applied the Anasept gel to the wound bed using a sterile swab, then covered the wound with a border gauze dressing that was dated. The staff reattached the resident's brief, put her pants back on, and applied the resident's shoes. The clinical record for Resident 47 was reviewed on 01/21/25 at 2:18 P.M. A Quarterly MDS assessment, dated 01/01/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, dementia and malnutrition. The resident was at risk for pressure ulcers and had one unhealed Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed) pressure ulcer. The current physician's order, with a start date of 01/01/25, indicated the treatment for the resident's right buttock was to cleanse the wound with Anasept spray, gently pat dry with sterile gauze, apply Skin Prep (a skin toughening agent) to the outside edge of the wound, apply collagen powder to the wound bed, apply Anasept gel, and cover with a bordered dressing. During an interview on 01/21/25 at 3:04 P.M., the ADON indicated the resident was admitted over a year ago and had the Stage 4 pressure wound. At the time of admission, the wound was big enough to put your fist in it and bone was visible. Healing had been a slow process, and the wound had worsened following a hospital stay. The wound was improving. The current treatment was to cleanse with Anasept spray, pat dry with sterile gauze, apply collagen powder to the wound bed, apply Anasept gel, and cover with a border dressing. Skin Prep was used to keep the area around the wound from becoming macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture). The Skin Prep should have been applied to the outside edges. The current GENERAL GUIDELINES FOR ADMINISTRATION OF MEDICATION policy, with an effective date of 12/01/22, was provided by the Administrator on 01/22/25 at 10:31 A.M. The policy indicated, .The nurse must clearly understand all medication orders before carrying them out . 3.1-40(a)(2)

Based on observation and interview, the facility failed to report the misappropriation of money for 1 of 1 resident reviewed for personal property. (Resident 16) Findings include: During an observation and interview on 11/27/23 at 1:54 P.M., Resident 16 was sitting in his room on his wheelchair. The resident indicated on Thanksgiving Eve (11/22/23) he had $1,024.00 missing from his fanny pack. He had gone to the bathroom, located in his room, to get cleaned up and placed the fanny pack in his recliner with a blanket over it. The next morning, he realized the money was missing. He reported it to a nurse, and she called the police. He had not talked to the Administrator as she had been off work. During an interview on 11/28/23 at 2:50 P.M., RN 4 indicated on the morning of 11/23/23, Resident 16 came to her saying he was missing $900.00. She had him recount his money just to make sure and she sent a message to the DON (Director of Nursing). She didn't hear anything back from the DON, so she called the police, and they came and talked to the resident. During an interview on 11/29/23 at 1:47 P.M., the Administrator indicated she had interviewed all of the staff and other residents. She could not confirm that staff had taken the resident's money as he had lots of outside visitors. The resident had been educated to not have large sums of money on him and he had been offered to place his money in a trust with the business office. He had since gotten a safe and was putting his money in there. Law enforcement was still involved and it was an open case. She should have been contacted immediately when the resident reported the missing money on 11/22/23. She was not notified until 11/27/23. She reported the incident as soon as she was notified. The current facility policy titled, Abuse and Neglect Procedural Guideline with a revised date of 08/29/2019, was provided by the Administrator on 11/29/23 at 3:02 P.M. The policy indicated, .Reporting/response .Any staff member, resident, visitor or resident representative may report known or suspected abuse, exploitation, neglect, or misappropriation to local or state agencies. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made . 3.1-13(g)(1)

Based on observation and interview, the facility failed to label and store medications appropriately for 1 of 2 medications carts (200 Hall) and 1 of 1 medication rooms (Health Care Medication Room) observed. Findings include: 1. The 200 Hall Medication Cart was observed on 12/04/23 at 9:08 A.M., with RN 6 and contained the following: - a Lispro insulin pen for Resident 108, containing 100 units of insulin, with no open date, - an unopened Basalgar insulin pen for Resident 108 with a sticker that indicated to refrigerate until opened. The pen was in the same package as an opened Basalgar pen for the resident. The RN indicated the one pen was not opened and should have been in the refrigerator, - a Lantus insulin pen for Resident 40, containing about 30 units of insulin, with no open date, and - a Novolog insulin pen for Resident 37, containing 200 units of insulin, with no open date. RN 6 indicated the insulin pens were good for 28 days after they were opened and should have all been labeled with an open date. The current Humalog Insulin Lispro Instruction for Use was provided by the DON (Director of Nursing) on 12/04/23 at 9:53 A.M. The instructions indicated, .Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin . The current Basaglar Instructions for Use was provided by the DON on 12/04/23 at 9:53 A.M. The instructions indicated, .Store unused pens in the refrigerator . The current Lantus Package Insert with a revision date of December 2020, was provided by the DON on 12/04/23 at 9:53 A.M. The insert indicated, .Shelf life after first use of the pen .The medicinal product may be stored for a maximum of 4 weeks . The current Novolog Instructions for Use with a revised date of December 2012, was provided by the DON on 12/04/23 at 9:53 A.M. The instructions indicated, .Store the FlexPen you are currently using out of the refrigerator .for up to 28 days . 2. During an observation and interview of the Health Care Medication Room with RN 7 the refrigerator contained a vial of Tuberculin Serum. The bottle was 1/4 full. The bottle was undated. RN 7 indicated the serum was good for 30 days after it was opened. During an interview on 12/04/23 at 9:53 A.M., the DON indicated the TB serum was delivered from the pharmacy on 10/16/23. There was no way to determine when the serum was opened. The current Apisol Package Insert was provided by the DON on 12/04/23 at 9:53 A.M. The package insert indicated, .Vials in use for more than 30 days should be discarded . 3.1-25(j) 3.1-25(k)(6)

Based on observation, interview, and record review, the facility failed to follow the physician's orders related to [CONDITION(S)], to complete neurological assessments related to falls, and to initiate monitoring of a wound for 1 of 14 residents reviewed for quality of care. (Resident 45) Findings include: 1a. During an observation on 09/23/22 at 9:56 A.M., Resident 45 was lying in her bed, awake. The clinical record for Resident 45 was reviewed on 09/26/22 at 11:52 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/23/22, indicated the resident was cognitively intact. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An open-ended physician's order, with a start date of 12/14/21, indicated the nursing staff were to check the resident's blood sugar (blood glucose) once a day, from 1:00 A.M. to 3:00 A.M. An open-ended physician's order, with a start date of 12/16/21, indicated if the resident's blood sugar was 50 to 69, the nursing staff were to give the resident a 15-gram carbohydrate oral feeding four times a day as needed, and wait 15 minutes and recheck blood sugar. If the blood sugar was less than 70, staff were to repeat the 15-gram of carbohydrate snack. The 15-gram carbohydrate, oral feeding, included one of the following: - 1 tube of glucose gel, - 4 ounces of any juice without adding sugar, - 4 ounces of regular soda pop, or - 8 ounces of low-fat/non-fat milk. The July and September 2022 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had the following blood sugars: - 07/31/22, a blood sugar of 57, - 09/25/22, a blood sugar of 58, and - 09/26/22, a blood sugar of 56. The resident's clinical record lacked any documentation that the resident had received a snack or that the MD was notified of the blood sugars. During an interview on 09/28/22 at 2:22 P.M., RN 7 indicated if a resident had an out of range vital, such as blood sugar, she would notify the MD and document any new orders as appropriate. Resident 45 was a brittle diabetic. The facility had a protocol if a residents' blood sugar was 60 or below the nurse was to follow the instructions on the order and call the MD for further orders. She would also notify the family. During an interview on 09/28/22 at 3:06 P.M., the DON (Director of Nursing) indicated the resident had an order to monitor the blood sugar in the middle of the night to monitor for [CONDITION(S)]. If the resident had a low blood sugar the nurse should offer her a snack or follow the hypoglycemic protocol. If the resident was coherent, they would offer oral measures. If the resident's blood sugar was below 60 the nurses should document in the EMAR/ETAR, or a progress note the type of intervention that was used. The resident had not suffered ill effects and did not have to be sent to the hospital due to the low blood sugars. The current facility policy, titled Hyper/[CONDITION(S)], with a review date of 03/18/22, was provided by the DON on 809/29/22 at 9:10 A.M. The policy indicated, .To ensure appropriate medical treatment is provided to residents experiencing hyper/hypoglycemic episodes . 1b. During an observation and interview on 09/23/22 at 9:56 A.M., Resident 45 was lying in her bed, awake. She indicated she had a sore on the top of one of her right toes. She was unsure what happened to it and had noticed it was bleeding a few days prior. The nursing staff would come in and check on it. There currently was no dressing on the toe. There was a pencil eraser size area to the toe that was pink in color. During an observation on 09/26/22 at 10:27 A.M., Resident 45 was lying in her bed. Her call light was in reach. She was awake and alert. The resident's right foot was without a sock. Her forth toe was dark in color. The clinical record lacked any indication the resident had an area to her right forth toe. During an interview on 09/29/22 at 9:31 A.M., RN 10 indicated the resident had a spot on one of her right toes that had been there for a few weeks. They were applying skin prep to the toe and covering it with a band aid. When a resident had a new skin area, the nurse would open an event. The event would talk about the wound and the size. If the resident had an area that was just red and not open, then they wouldn't create an event for it. They would have an order to monitor it each shift. The resident did not have an order to monitor the toe. During an observation and interview on 09/29/22 at 9:46 A.M., the resident was sitting in her wheelchair in the bathroom. She gave permission for the ADON (Assistant Director of Nursing) to observe her toe. The ADON washed her hands and donned gloves. She removed the resident's sock and band aid to the right forth toe. The resident had a blister that was dark purple in color. The ADON indicated she was unaware of the area and if a resident had a new skin condition the nurse would create an event or progress note. The resident should have had an event and monitoring of the toe. A Skin Integrity Event, dated 09/29/22 at 10:07 A.M., indicated the resident had a blister the right forth toe. The area measured 1 cm (centimeter) X (by) 1 cm. A treatment was in place for skin prep to the blister and cover with a band aid. The Nurse Practitioner was notified. The current facility policy titled Bruise, Rash, Lesion, Skin Tear, Laceration Assessment, with a most recent revision date of 05/10/16, was provided by the DON on 09/29/22 at 10:25 A.M. The policy indicated, .May complete Skin Tear/Laceration Event in EHR (Electronic Health Record) .if the Skin Tear/Laceration warrants documentation due to the extent and/or location .One weekly follow-up assessment may be completed to ensure .in the process of healing .If further follow-up is needed, documentation may be placed in a progress note . 1c. During an observation on 09/28/22 at 12:40 P.M., Resident 45 was sitting in the dining room with her family member. There were no concerns observed. During an interview on 09/28/22 at 2:22 P.M., RN 7 indicated when a resident had a fall, she would assess the resident for injuries. If the resident was able to be moved, then they would be assisted up. If the resident's fall was unwitnessed or if they hit their head the nurse would complete neurological assessments for 24 hours. The nurse would initiate an immediate intervention and then the management team would either agree or disagree with the intervention. During an interview on 809/28/22 at 3:06 P.M., the DON (Director of Nursing) indicated when a resident had a fall the nurse would complete their assessment, open a fall event, and notify the family and MD. The nurse would implement an immediate intervention. The IDT (Interdisciplinary Team) would review the fall and either agree or disagree with the intervention. If they had disagreed with the immediate intervention a new intervention would be initiated immediately. The neurological checks would be initiated for 24 hours if a resident's fall was unwitnessed, or if they hit their head. A Fall Event, dated 04/12/22 at 12:25 A.M., indicated the resident had an unwitnessed fall in the bathroom. There were no injuries noted. The resident had neurological checks completed for the first hour after the fall. A Fall Event, dated 04/13/22 at 3:08 A.M., indicated the resident had an unwitnessed fall in the bathroom. The resident had obtained a skin tear to the left forearm. The resident had neurological checks completed for the first hour after the fall. The clinical record lacked documentation the neurological checks were completed for 24 hours after the falls. During an interview on 09/29/22 at 11:01 A.M., the DON indicated the resident should have neurological checks completed for 24 hours after each unwitnessed fall. The current facility policy titled, Guidelines for Neurological Checks, with a revised date of 03/16/22, was provided by the DON on 09/29/22 at 11:15 A.M. The policy indicated, .to evaluate the level of consciousness, evaluate pupil response, motor function, and vital signs that may alert staff for potential for head injury or [CONDITION(S)] activity .Neuro-checks for 24 hours should be completed within the Fall Event Form . 3.1-37(a)

Based on interview, observation, and record review, the facility failed to prevent the formation of a pressure ulcer and an increase in the stage (severity) of a pressure ulcer for 1 of 3 residents reviewed. (Resident 41) Findings include: During an interview on 09/22/22 at 1:10 P.M., Resident 41 indicated the wound on his foot bothered him sometimes. During an interview on 09/27/22 at 11:28 A.M., the DON (Director of Nursing) indicated the resident was admitted from another facility, was a type 1 diabetic, and had several ulcers to both heels and toes. He started being seen at the wound clinic while a resident at this facility. If the facility saw that a wound was not healing well, they would get an outside opinion from a specialist. He admitted to this facility with a stage 2 (partial thickness skin loss with exposed dermis) pressure ulcer to his left heel. The wound had eschar (dry, dead) tissue now and it was an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown] and/or eschar [tan, black or brown] in the wound bed) pressure ulcer. He currently had a Podus (pressure relieving foam) boot in place. They had gotten an order to take the Podus boot off at night due to the resident obtaining stage 1(intact skin with non-blanchable redness of a localized area) pressure ulcers to the top of his foot and lateral ankle from the boot. His skin was very fragile. They had a wound nurse, the ADON (Assistant Director of Nursing) assessed the wounds weekly, measured them, and notified the physician if the wounds had gotten worse. They were required to get an order from the physician in order to send a resident to the wound clinic. When asked what happened between 07/05/22 and 07/26/22 the DON indicated they may have opened up a new wound management record due to the change in the stage of the wound. During an interview on 09/27/22 at 3:15 P.M., RN 7 indicated the resident had been non compliant related to his diabetes for a long time. During an interview on 09/28/22 09:46 AM., CNA (Certified Nurse Aide) 6 indicated the resident could scoot himself around in bed but required staff assistance with turning. The resident's wounds on his left lower extremity were observed on 09/28/22 at 10:19 A.M., with the DON and the ADON. The resident was lying in bed wearing his protective foam boot. The staff removed the boot, unwrapped the foot and ankle and took off the foam protective pads that had been held in place by the gauze wrap. The wound on the resident's left ankle was closed and had a thin red/pink line that was healing. The wound on the resident's heel was a dime size wound with a black wound bed. The surrounding skin was pink and healing. No odor or drainage was observed on the dressing. An Admission MDS (Minimum Data Set) assessment, dated 06/10/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at risk for pressure ulcers and had unhealed pressure ulcers, one stage 2 pressure ulcer and one unstageable pressure ulcer that were present on admission. A Discharge MDS assessment, dated 08/08/22, indicated the discharge was not anticipated. An Entry MDS assessment, dated 08/11/22, indicated the resident returned to the facility from an acute hospital stay. The Wound Management Log for the resident's pressure ulcers (PU) was provided by the DON on 09/27/22 at 1:42 P.M., and included, but was not limited to, the following: 1. Left ankle PU (not present on admission, developed in-house on 07/26/22): - dated 07/26/22, stage 2 PU, 0.7 cm (centimeters) x (by) 1 cm, (no measurable depth noted), - dated 08/02/22, stage 3 PU (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed), 0.5 cm x 0.7 cm x 0.2 cm deep, and - dated 09/22/22, no stage identified, 0.3 cm x 0.3 cm (no measurable depth noted). 2. Left Heel PU (present on admission, 06/03/22): - On 07/05/22, stage 2 PU, 2 cm x 1 cm (no measurable depth noted), - On 07/20/22, stage 3 PU, 2.5 cm x 2.5 cm x 0.1 cm deep, and - On 09/22/22, unstageable, 1 cm x 1.8 cm (no measurable depth noted). The clinical record lacked documentation the wound was assessed and measured between 07/05/22 and 07/20/22. The EMAR/ETAR (Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment was to be documented as 0 = (equals)no impairment, 1 = new impairment, 2 = old impairment. The assessments were completed on 07/09/22 and 07/16/22 and were documented with 0, indicating the resident had no current skin impairments. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A lab results report, dated 08/23/22, was provided by the DON on 09/27/22 at 3:21 P.M., and indicated the resident had a left lower extremity venous ultrasound. The vessels demonstrated normal blood flow. A Care Plan, with a start date of 06/16/22, was provided by the DON on 09/27/22 at 3:21 P.M., and indicated the resident had multiple pressure ulcers on the left lower extremity. Interventions included, but were not limited to, weekly skin assessments, measurement, and observation of the ulcers and record. The current Guidelines for Weekly Skin Observations policy, with a reviewed date of 03/16/22, was provided by the DON on 09/28/22 at 11:25 A.M. The policy indicated, .The nurse completing the weekly skin check shall indicate the appropriate number (0,1, 2) medication note . The current Pressure/Stasis/Arterial/Diabetic Wound Guidelines policy, with a reviewed date of 11/15/21, was provided by the DON on 09/28/22 at 11:25 A.M. The policy indicated, PURPOSE .To provide weekly documentation of wound measurements and condition . 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to follow and intervention after a fall for 1 of 3 residents reviewed for accidents. (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 09/26/22 at 11:52 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/23/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, diabetes, [CONDITION(S)], anxiety, depression, [CONDITION(S)], and [CONDITION(S)]. A Fall Event, dated 02/28/22 at 10:04 P.M., indicated the resident slid out of bed while attempting to transfer. There were no injuries noted. An IDT (Interdisciplinary Team) note, dated 03/02/22 at 8:21 A.M., indicated the root cause of the fall was the resident had slid off her low air loss mattress. A new intervention was to remove the low air loss mattress. A Fall Event, dated 03/14/22 at 3:50 A.M., indicated the resident had rolled out of bed. There was a low air loss mattress in place. There were no injuries noted. An IDT note, dated 03/14/22 at 2:59 P.M., indicated the root cause was that the resident had slid out of bed. The immediate intervention was to remove the low air loss mattress. During an interview on 09/28/22 at 2:22 P.M., RN 7 indicated when a resident had a fall, she would assess the resident for injuries. If the resident was able to be moved, then they would be assisted up. If the resident's fall was unwitnessed or they hit their head the nurse would complete neurological assessments for 24 hours. The nurse would initiate an immediate intervention and then the management team would either agree or disagree with the intervention. During an interview on 809/28/22 at 3:06 P.M., the DON (Director of Nursing) indicated when a resident had a fall the nurse would complete their assessment, open a fall event, and notify the family and MD. The nurse would implement an immediate intervention. The IDT would review and either agree or disagree with the intervention. If they had disagreed with the immediate intervention a new intervention would be initiated immediately. The neurological checks would be initiated for 24 hours if a resident's fall was unwitnessed, or they hit their head. The resident's low air loss mattress should have been removed when she had the fall on 02/28/22. The current facility policy titled, Fall Management Program Guidelines with a review date of 03/16/22, was provided by the DON on 09/29/22 at 9:10 A.M. The policy indicated, .to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures .should the resident experience a fall the attending nurse shall complete the Fall Event, this includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions .Discuss risks and interventions with resident and/or responsible party and communicate interventions during shift report . 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident received a regulatory physician's visit every 60 days for 1 of 14 residents reviewed. (Resident 10) Findings include: The clinical record for Resident 10 was reviewed on 09/26/22 at 11:14 A.M. The resident was admitted to the skilled nursing department of the facility on 08/30/21. Prior to 08/30/21, the resident resided in the assisted living area of the facility. A Quarterly MDS (Minimum Data Set) assessment, dated 09/09/22, indicated the resident had short term memory problems and was moderately cognitively impaired for daily decision making. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/28/22 at 10:18 A.M., LPN (Licensed Practical Nurse) 9 indicated the resident's family member took her to her doctor appointments. The resident would see her doctor in his office, he did not see her in the facility. The resident did not see the Nurse Practitioner that came into the facility. Her family member took her to the doctor every 3 months or so. The Physician notes from the resident's in-office visits were provided by Clinical Support Nurse 8 on 09/28/22 at 11:44 A.M. and included the following: - The resident went to her physician's office and had an annual wellness visit on 01/25/22. Physician's notes indicated the resident should follow up in 4 months or as needed for her [CONDITION(S)] diagnosis. - A referral form dated 05/23/22 indicated the resident was seen in the office by her physician. A progress note indicated the resident's chronic condition appeared to be stable. The resident's next appointment was in 4 months. - A referral form dated 09/23/22 indicated the resident was seen in the office by her physician. A progress note indicated the resident's family member reported the resident was overall stable but had experienced some weight loss. The resident was to continue her current medications. The resident's next appointment was in 4 months. The resident's clinical record lacked a physician's visit at least one every 30 days for the first 90 days after admission and one every 60 days thereafter. The current facility policy, titled Guidelines for Physicians Services was provided by Clinical Support Nurse 8 on 09/28/22 11:25 A.M. at 11:25 A.M. The policy indicated, .To provide care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Physician visits, frequency of visits .are provided in accordance with current OBRA regulations and campus policy . 3.1-22(d)(1)

Based on observation, interview, and record review, the facility failed to address the pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications. (Resident 44) Findings include: Resident 44 was observed in his room on 09/27/22 at 11:01 A.M. The resident was in bed but indicated he would be getting up and going to lunch soon. The resident was pleasant and denied any concerns. The resident's clinical record was reviewed on 09/26/22 at 1:46 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 05/21/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, [CONDITION(S)], hypertension, and Non-Alzheimer's dementia. The resident was receiving hospice services. The resident's medication orders were reviewed and included an order from the resident's neurologist, with a start date of 10/27/21, for [MEDICATION(S)] (a cognition enhancing medication, used to treat Alzheimer's disease) 5 mg (milligrams) daily. That order was discontinued on 05/09/22, and a current, open ended order, with a start date of 05/10/22, for [MEDICATION(S)] 10 mg daily began. The resident received the medication daily as ordered. A Pharmacy Recommendation Event, dated 06/08/22, indicated the following: - At the top of the recommendation was a highlighted area that requested the recommendation be sent to the resident's neurologist and included his name and phone number. The recommendation went on to say that the resident's most recent MDS assessment indicated he was severely cognitively impaired. The American Geriatric Society found that de-prescribing medications like [MEDICATION(S)] was not associated with negative effects to the resident and would likely help reduce the risk of falls and fractures in older nursing home residents with dementia. The pharmacist recommended they consider discontinuing the [MEDICATION(S)] medication at that time. - The Pharmacy Recommendation Event was closed on 06/20/22 by the ADON (Assistant Director of Nursing). The evaluation notes indicated there were no new physician's orders. There was no indication that the physician agreed or disagreed with the recommendation, those questions were marked NA. The resident's clinical record lacked any other documentation related to the pharmacy recommendation. During an interview on 09/29/22 at 12:08 P.M., the DON (Director of Nursing) indicated the ADON usually handled pharmacy recommendations. The recommendation would be forwarded to the prescribing physician. The physician's response, whether they agreed with the recommendation or if they declined the recommendation would be documented in the resident's clinical record. The physician would provide rationale if they declined the pharmacy recommendation. During an interview on 09/29/22 at 11:36 A.M., Clinical Support Nurse 8 indicated the facility could not provide a specific policy for pharmacy recommendations. 3.1-25(i)

Based on observation, interview, and record review, the facility failed to follow manufacturer's guidelines related to insulin pen usage for 2 of 2 medication administration observations. (Residents 48 and 1) Findings include: 1. During an observation on 07/30/21 at 11:23 A.M., LPN (Licensed Practical Nurse) 3 cleaned the end of the Novolog insulin pen, applied the needle, held the pen sideways, and primed the pen with insulin coming out as she primed the pen. She turned the pen to the amount needle and went into Resident 48's room to administer the insulin. She administered the insulin in the right side of the resident's abdomen. She did not hold the pen in place after the injection to allow complete delivery of the medication. The clinical record for resident 48 was reviewed on 08/02/21 at 11:12 A.M. An Annual (MDS) Minimum Data Set assessment, dated 07/16/21, indicated the resident was moderately cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Novolog package insert, with a revised date of 11/2019, was provided by the DON on 08/03/21 at 9:47 A.M. The insert indicated, .Before each injection .To avoid injecting air and to ensure proper dosing .Turn the dose selector to select 2 units. Hold your insulin .[MEDICATION(S)] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the bottom all the way in .A drop of insulin should appear at the needle tip .Keep the needle in the skin for at least 6 seconds . 2. During an observation on 07/30/21 at 11:38 A.M., LPN 3 cleaned the end of the [MEDICATION(S)] insulin pen, applied the needle, held the pen sideways, and primed the pen with the cap still on the needle. The end of the needle was not visible to see if insulin was coming out as she primed the pen. She turned the pen to the amount needed and went into Resident 1's room to administer the insulin. She administered the insulin in the left side of the resident's abdomen. She did not hold the pen in place after the injection to allow complete delivery of the medication. The clinical record for Resident 1 was reviewed on 08/02/21 at 11:22 A.M. An Annual MDS assessment, dated 06/29/21, indicated the resident was cognitively sound. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current [MEDICATION(S)] (Lispro) package insert, with a revised date of 11/2019, was provided by the DON on 08/03/21 at 9:47 A.M. The insert indicated, .If you do not prime before each injection, you may get too much or too little insulin .To prime your pen, turn the Dose Knob to select 2 units. Hold your pen with the needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with the Needle pointing up. Push the Dose Knob in until it stops .Giving your injection .Continue to hold the Dose Knob in and slowly count to 5 before removing the needle . During an interview on 07/30/21 at 11:58 A.M., RN 4 indicated when administering insulin she would clean the end of the insulin pen, place the needle on the pen, remove the cap of the needle, turn the dial to one unit hold the pen upright, push the pen so the insulin came out of the needle, dial the resident's correct dosage, clean the skin with alcohol, inject the needle, push the end releasing the insulin, and hold the pen in place for a count of 10. During an interview on 08/02/21 at 1:27 P.M., RN 5 indicated when administering insulin she would clean the tip of the insulin pen, place the needle on the pen, dial two units, hold the pen upright push to see the liquid come out of the needle, dial the dosage to be given to the resident, clean the area of skin, inject the needle, hold for a count of five, then remove from the resident's skin. During an interview on 08/04/21 at 2:10 P.M., the Corporate Nurse indicated the facility had no specific policy related to priming insulin pens. 3.1-47(a)(1)

Based on record review, observation, and interview, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheters for 1 of 2 residents reviewed for catheter care (Resident 38) Findings include: The clinical record for Resident 38 was reviewed on 07/29/21 at 2:54 P.M. An Annual MDS assessment, dated 07/16/21, indicated the resident was severely cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An indwelling urinary catheter was in place. The resident required the assistance of two staff members to transfer. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 08/02/21 at 12:03 P.M., Resident 38 was sitting in her wheel chair in her room waiting for her lunch to be served. The tubing of her urinary catheter was laying on the floor under her wheel chair. The door to her room was open and the resident was visible from the hall. During an observation on 08/02/21 at 2:17 P.M., Resident 38 was sitting in her wheel chair in her room facing the hallway with the urinary catheter tubing laying on the floor under the wheel chair. Her lunch plate had been removed from her bed side table. During an observation on 08/02/21 at 2:37 P.M., Resident 38 was propelling herself in her wheel chair in her room while the urinary catheter tubing was dragging on the floor under her wheel chair. During an interview on 08/02/21 at 2:41 P.M., CNA 6 indicated a urinary catheter bag should hang lower than the bladder, be placed in a dignity bag, and the tubing should not touch the floor. The current URINARY CATHETER CARE policy, dated 11/05/2016, was provided by the Corporate Nurse on 08/02/21 at 2:43 P.M., and indicated, .To prevent infection of the resident's urinary tract .Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to follow physician's orders related to medication administration for 2 of 6 residents reviewed for unnecessary medications. (Residents 22 and 43) Findings include: 1. The clinical record for Resident 22 was reviewed 07/29/21 at 2:42 P.M. An Admission MDS (Minimum Data Set) assessment, dated 05/14/21, indicated the resident was severely cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An open ended physician's order, dated 06/10/21, indicated [MEDICATION(S)] (a hypertension medication) 12.5 mg (milligrams), twice a day, for hypertension and to hold the medication if the systolic blood pressure was less than 100 and the heart rate was less than 60 bpm (beats per minute). The clinical record including the June and July 2021 EMAR (Electronic Medication Administration Record) lacked documentation the heart rate had been monitored prior to the medication administration for the following dates and times: - 06/10/21 from 6:00 P.M. to 10:00 P.M., - 06/11/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 06/12/21 from 6:00 P.M. to 10:00 P.M., - 06/13/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 06/15/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 06/17/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 06/18/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 06/19/21 from 6:00 P.M. to 10:00 P.M., - 06/22/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 06/23/21 from 6:00 A.M. to 10:00 A.M., - 06/24/21 from 6:00 P.M. to 10:00 P.M., - 06/25/21 from 6:00 P.M. to 10:00 P.M., - 06/26/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 06/27/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 06/28/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 06/30/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/01/21 from 6:00 A.M. to 10:00 A.M., - 07/02/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/03/21 from 6:00 P.M. to 10:00 P.M., - 07/04/21 from 6:00 P.M. to 10:00 P.M., - 07/05/21 from 6:00 A.M. to 10:00 A.M., - 07/06/21 from 6:00 P.M. to 10:00 P.M., - 07/07/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/08/21 from 6:00 A.M. to 10:00 A.M., - 07/09/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/10/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/11/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/12/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/13/21 from 6:00 A.M. to 10:00 A.M., - 07/14/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/15/21 from 6:00 P.M. to 10:00 P.M., - 07/16/21 from 6:00 P.M. to 10:00 P.M., - 07/17/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/18/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/19/21 from 6:00 A.M. to 10:00 A.M., - 07/20/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/21/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/22/21 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., - 07/23/21 from 6:00 P.M. to 10:00 P.M., - 07/24/21 from 6:00 P.M. to 10:00 P.M., - 07/25/21 from 6:00 P.M. to 10:00 P.M., - 07/28/21 from 6:00 P.M. to 10:00 P.M., - 07/29/21 from 6:00 A.M. to 10:00 A.M. During an interview on 07/30/21 at 11:18 A.M., QMA (Qualified Medication Aide) 12 indicated if a resident had hold parameters on a medication then staff would obtain the vital sign levels and put them in the computer. The computer would give them the option to give or not give the medications. If the medication was to be held for any reason she would alert the physician. 2. The clinical record for Resident 43 was reviewed on 08/02/21 at 2:36 P.M. An Admission MDS assessment, dated 07/03/21, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMAR was provided by the DON (Director of Nursing) on 07/30/21 at 1:32 P.M. A physician's order, with a start date of 06/26/21, indicated the resident was to receive the medication [MEDICATION(S)], 100 mg, once a day, for hypertension. The medication was to be held, not given, if the resident's systolic blood pressure, the top number, was less than 100, or the heart rate was less than 60 bpm (beats per minute). The EMAR documentation indicated the resident was given the medication when their heart rate was out of the prescribed range on the following dates: - 07/08/21, heart rate 59, - 07/19/21, heart rate 59, and - 07/30/21, heart rate 58. The complete Care Plan was provided by the DON on 07/30/21 at 1:32 P.M. A Care Plan, with a start date of 07/09/21, indicated the resident had the potential for cardiovascular distress related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Medications as ordered .Obtain vital signs as ordered . The current Medication Administration General Guidelines policy, with a revised date of 11/2018, was provided by the Corporate Nurse on 08/03/21 at 3:17 P.M. The policy indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . 3.1-48(a)(1) 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to prevent a pressure ulcer for 1 of 1 resident reviewed for pressure ulcers. (Resident 22) Findings include: During an observation on 07/30/21 at 10:32 A.M., Resident 22 was sitting in her wheelchair in her room. RN 4 informed the resident she was going to change the dressing to her left foot. CNA (Certified Nurse Aide) 7 and RN 4 washed their hands appropriately and applied gloves. CNA 7 removed the heel protector boot from the resident's left foot and held the foot in place. RN 4 removed the dressing from the resident's left foot and washed her hands. The wound was pink. There was no odor or signs of infection. RN 4 cleansed the wound with normal saline. The wound measured 0.2 cm (centimeters) X 0.3 cm. There was pink skin surrounding the entire heel. RN 4 applied [MEDICATION(S)] gel, gauze, and a dressing to the left heel. CNA 7 reapplied the heel protector boot. During an interview on 07/30/21 at 11:55 A.M., the ADON (Assistant Director of Nursing) indicated the resident had developed a DTI (Deep Tissue Injury) (non blanchable deep red, purple or maroon areas of intact skin, non intact skin or blood filled blisters) on 06/22/21. The resident had lived on the locked dementia unit, had fallen, and broke her hip. She had surgery and returned to the facility for therapy. She was in a knee immobilizer to keep her leg straight. The resident was non-compliant with keeping her leg elevated and keeping it off of the wheelchair pedal. Heel protectors were put into place on 06/22/21. They floated heels for every resident. The resident was care planned for non-compliance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident 22 was reviewed 07/29/21 at 2:42 P.M. An Admission MDS (Minimum Data Set) assessment, dated 05/14/21, indicated the resident was severely cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for pressure ulcers but had no pressure ulcers during the assessment period. A Wound Management Detail Report, dated 06/22/21, indicated the resident had developed a DTI to the left heel on 06/22/21. The wound measured 2.5 cm X 6 cm. The blister remained intact. The treatment was to apply skin prep followed by an adhesive foam heel protector and a heel protector boot. A Wound Management Detail Report, dated 06/30/21, indicated the DTI measured 2.4 cm X 5.6 cm and was a fluid filled vesicle that remained intact. The peri-wound was normal in appearance. There were no signs or symptoms of infection. The heel protector boot, adhesive foam heel protector, and skin prep treatment continued. A Wound Management Detail Report, dated 07/06/21, indicated the wound measured 3.2 cm X 5 cm. The blister was no longer intact. There was minimal clear serous (mostly clear or slightly yellow thin plasma that is just a bit thicker than water) drainage with no signs or symptoms of infection. The peri-wound was normal in appearance and the blister roof was dry. The heel protector boot, adhesive foam heel protector, and skin prep treatment continued. A Wound Management Detail Report, dated 07/21/21, indicated the wound measured 4 cm X 4 cm. The peri-wound was macerated (softening and breaking down of skin). The dead skin from the ruptured blister was trimmed by the Nurse Practitioner. There was some purulent (thick and milky discharge) drainage noted and an order was received for a wound culture. Treatment was to continue with heel protector boots along with adhesive foam heel protector, allevyn spray daily, and skin prep to the peri-wound. A Wound Management Detail Report, dated 07/29/21, indicated the wound measured 6.2 cm X 5.5 cm. The wound culture showed no growth and ordered antibiotics were discontinued. The wound bed was dry and no longer macerated. The area was pink and blanchable and completely resurfaced except for 0.6 cm X 0.4 cm area. The treatment was to apply [MEDICATION(S)] to the small open area daily along with the adhesive dressing and heel protector boots. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Care Plan, dated 05/20/21, indicated the resident was at risk for skin breakdown related to incontinence status and decreased mobility with the need of staff assistance with ADL (Activity of Daily Living) and transfers. Interventions included the following: - Avoid shearing skin during positioning, transferring, and turning, - Conduct a weekly skin inspection as needed. Pay particular attention to bony prominences, - Encourage and assist to turn and reposition as needed to relieve pressure, - Encourage fluids unless contraindicated, - If incontinence occurs, provide incontinence care after each incontinence episode. Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness of the skin; avoid friction to the skin, - Keep clean and dry as possible. Minimize skin exposure to moisture, - Keep linens clean and dry, - Pressure reducing mattress to bed, - Report any signs of skin breakdown (sore, tender, red, or broken areas), - Use lifting device as needed for bed mobility, - Use moisture barrier product to perineal area as possible. A Care Plan, dated 05/24/21, indicated the resident demonstrated non-compliance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included the following: - Assess for need for a guardian or other legal oversight as needed, - Educate resident regarding physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Encourage resident to actively participate in care plan and decision making, - Encourage resident to participate in decision making by offering choices and discussion of advance directives, - Monitor resident's ability to give informed consent and fluctuations in decision making. There were no appropriate interventions put into place for the resident resting her foot on the floor when the resident was severely cognitively impaired. The current facility policy titled, Guidelines for Pressure Prevention, with a revision date of 05/10/2017, was provided by the DON (Director of Nursing) on 08/02/21 at 2:58 P.M. The policy indicated, .To maintain good skin integrity and avoid development of pressure ulcers . 3.1-40(a)

Based on observation, interview, and record review, the facility failed to ensure infection control practices for COVID-19 were followed during the pandemic, related to failing to identify symptoms of COVID-19 and did not isolate the residents with symptoms to help mitigate the spread of COVID-19 for 4 of 4 residents reviewed for infection control. (Residents B, E, C, F) The Immediate Jeopardy began on 10/02/20, when the facility failed to identify symptoms of COVID-19 and did not isolate the residents to help mitigate the spread of COVID-19. The Administrator was notified of the Immediate Jeopardy on 10/09/20 at 05:47 P.M. Findings include: 1. The clinical record for Resident B was reviewed on 10/9/20 at 11:45 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/14/20, indicated the resident was severely cognitively impaired. [DIAGNOSES REDACTED]. The resident resided on the 100 hall. An open ended physician's orders [REDACTED]. If over 100 degrees, open appropriate event and notify the MD/ NP (Nurse Practitioner). The Vitals Report for October 2020 indicated the resident had elevated temperatures on the following dates and times: - 10/02/20 at 6:33 P.M., temperature of 101.4 degrees Fahrenheit, - 10/03/20 at 8:21 A.M., temperature of 100.7 degrees Fahrenheit, - 10/03/20 at 12:47 P.M., temperature of 99.7 degrees Fahrenheit, - 10/03/20 at 8:58 P.M., temperature of 101.8 degrees Fahrenheit, - 10/03/20 at 11:39 A.M., temperature of 99.6 degrees Fahrenheit, - 10/04/20 at 9:42 A.M., temperature of 99.8 degrees Fahrenheit, - 10/06/20 at 7:51 P.M., temperature of 100.1 degrees Fahrenheit An open ended physician's orders [REDACTED]. An open ended physician's orders [REDACTED]. The October 2020 EMAR (Electronic Medication Administration Record) indicated the resident received the as needed Tylenol on the following dates and times: - 10/03/20 at 9:42 A.M., for a fever of 100.7, - 10/03/20 at 9: 06 P.M., for fever - 10/04/20 at 4: 01 P.M., for fever and pain A Progress Note, dated 10/03/20 at 5:16 A.M., indicated the resident began running a fever at the beginning of the shift on the evening of 10/02/20. The resident has a skin wound to right flank and began Bactrim (antibiotic) DS on 10/02/20 in the A.M. The resident had no other symptoms of illness and no respiratory symptoms. The residents temperature was now 98.2. A Progress Note, dated 10/03/20 at 2:21 P.M., indicated the physician was contacted regarding the resident running temperatures despite ATB (antibiotic) treatment. The NP ordered CBC (Complete Blood Count) with differential, CMP (Complete Metabolic Panel), CRP (C- Reactive Protein) for inflammation, Procalcitoninc, and a UA (Urinalysis) C&S (Culture and Sensitivity). The NP stated to call her with the results. A Progress Note, dated 10/3/20 at 10:21 P.M., indicated the resident's labs were obtained. At 9 P.M., the resident had a temperature of 101.8 temporally and as needed Tylenol was given for fever. A Progress Note, dated 10/04/20 at 6:47 A.M., indicated the resident had was crying loudly on/off through the night. As needed Tylenol was given as ordered for pain and fever. Temperature 99.3 temporal at this time after as needed Tylenol was given at 4 A.M. A Progress Note, dated 10/06/20 at 7:18 P.M., indicated the resident was assessed at this time and was noted to have a temperature of 100.0, BP (Blood Pressure) 81/47, pulse 70, respirations 20, oxygen 93% on room air. The resident continues to state Don't feel good. MD notified of vital signs, complaints, and current diagnosis. Orders were received to send to the ER (emergency room ) for evaluation and treatment. A Progress Note, dated 10/07/20 at 3:45 A.M., indicated the resident arrived to the facility and has been moved to the red zone due to positive COVID-19 test. Resident will remain in isolation. A Physician assessment dated [DATE] indicated, .Intake .COVID Symptoms: Reports Fever >greater than 100.4 . The clinical record had no indication the resident had been placed in isolation until the positive COVID-19 result on 10/07/20. During an interview on 10/09/20 at 1:43 P.M., the Administrator indicated Resident B had not been placed on isolation until the positive COVID test on 10/07/20. 2. The clinical record for Resident E was reviewed on 10/09/20 at 3:27 P.M. A Quarterly MDS assessment, dated 07/29/20, indicated the resident was moderately cognitively impaired. [DIAGNOSES REDACTED]. The resident resided on the 100 hall and was a roommate to Resident F. An open ended physician's orders [REDACTED]. An open ended physician's orders [REDACTED]. The Vitals Report for September 2020 and October 2020 indicated the resident had elevated temperatures on the following dates and times: - 09/29/20 at 9:37 A.M., temperature of 99.0 degrees Fahrenheit, - 09/29/29 at 1:18 P.M., temperature of 99.0 degrees Fahrenheit, - 09/29/20 at 7:49 P.M., temperature of 99.1 degrees Fahrenheit, - 10/02/20 at 8:56 P.M., temperature of 102.4 degrees Fahrenheit, - 10/03/20 at 10:19 A.M., temperature of 99.7 degrees Fahrenheit, - 10/03/20 at 8:50 P.M., temperature of 99.8 degrees Fahrenheit, - 10/04/20 at 8:01 A.M., temperature of 99.8 degrees Fahrenheit, - 10/04/20 at 9:21 P.M., temperature of 100.7 degrees Fahrenheit A Physician Assessment, dated 10/3/20. Plan: Fever 1. We will go ahead and obtain a CBC with differential, basic metabolic panel and chest x-ray for evaluation. 2. Does not appear that she had a urinary tract infection at this time. 3. Per the director of nursing she just had a COVID test on 10/1/2020 we will go ahead and hold on repeating this at this time. Despite the fact that she is currently symptomatic as opposed to being an asymptomatic test yesterday . A Progress Note, dated 10/3/20 at 12:15 A.M., indicated that just prior to 9 P.M., the writer had went into the resident room to obtain temperature and oxygen saturation for COVID protocol monitoring. Temporal temp was noted to be 102.0. An oral temperature was taken and noted to be 102.4. Resident had denied any signs or symptoms of COVID, other illness, or pain. The physician was notified of the fever. Resident was then assessed by a physician via telehealth. New orders were obtained for a CBC and BMP (Basic Metabolic Panel) now as well as chest x-ray in the AM. COVID testing was not performed as the resident was last tested on [DATE] and results were pending at the time. A Metabolic/Nutrition Event--Abnormal Temperature Event, dated 10/02/20, indicated the resident had a temperature of 102.4. The clinical record had no indication the resident had been placed in isolation. During an observation on 10/09/20 at 3:48 P.M., Resident E was in her room with a roommate, Resident F. There was no indication the residents were in isolation. The room was across the hall diagonally from Resident B's room. During an interview on 10/09/20 at 12:33 P.M., LPN (Licensed Practical Nurse) 2 indicated that when a resident had an elevated temperature then they should be placed in the yellow hall on isolation and call the DON (Director of Nursing) and Administrator. If the resident had a roommate then they should be isolated too. When a resident is moved to the yellow hall then the nurse would document in a progress note. 3. The clinical record for Resident C was reviewed on 10/9/20 at 11:30 A.M. A Quarterly MDS assessment, dated 09/22/20, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. The resident received oxygen therapy during the assessment review period. The resident resided on the 100 hall of the facility. The room was 3 doors down on the same side of the hallway as Resident B. An open ended physician's orders [REDACTED]. An open ended physician's orders [REDACTED]. A Progress Note, dated 09/04/20 at 10:13 A.M., indicated the resident was currently on 4 liters of oxygen, and her O2 sat (oxygen saturation level) was 92%. The resident was in no distress and did not complain of shortness of air at that time. The NP (Nurse Practitioner) had been notified of an O2 sat of 89%. There were no new orders. A Progress Note, dated 09/25/20 at 7:53 A.M., that was recorded as a late entry on 09/28/20 at 7:55 A.M. and was edited due to incorrect data on 09/28/20 at 7:56 A.M. indicated the NP was aware of a resident episode of low oxygen saturation with no new orders. The resident's lungs were clear, and the resident remained afebrile. The resident had a [DIAGNOSES REDACTED]. The resident's O2 sat levels had remained normal since that time and the resident remained asymptomatic. A Progress Note, dated 10/07/20 at 11:48 A.M., indicated the resident had been tested for COVID-19 and the results were pending. A Progress Note, dated 10/07/20 at 11:49 A.M., indicated the resident was noted to have a low O2 sat that was confirmed by nursing staff. The NP confirmed low air movement in the residents lungs and gave a new order to the the resident to the ER to evaluate and treat for hypoxemia, and an increased complaint of shortness of air. The resident was transferred. A Progress Note, dated 10/09/20 at 1:57 P.M., indicated the Resident tested positive for the rapid COVID-19 test that was performed at the local hospital. The Resident was expected to return to the facility in isolation in the red zone. A Physician Assessment, dated 10/07/20 indicated, .Intake .COVID Symptoms: Reports Shortness of Breath .seen today for an acute visit for staff report of low SpO2. Staff report SpO2 is 73-78% on 4L per NC (nasal cannula) .(resident) appears extremely short of breath .lips are cyanotic .denies chest pain .denies fever or chills .reports increasing shortness of breath the last couple of days . The clinical record had no indication the resident had been placed in isolation prior to the resident being sent to the local hospital on [DATE]. 4. The clinical record for Resident F was reviewed on 10/09/20 at 2:26 P.M. An Admission MDS assessment, dated 09/04/20 indicated the resident was moderately cognitively impaired. [DIAGNOSES REDACTED]. The resident did utilize oxygen therapy during the assessment review period. The resident resided on the 100 hall, and was a roommate of Resident E. The room was across the hall, diagonally from Resident B's room. An open ended physician's orders [REDACTED]. An open ended physician's orders [REDACTED]. The Vitals Report for September and October 2020 indicated the resident had elevated temperatures on the following dates and times: - 09/11/20 at 7:54 P.M., temperature of 99.6 degrees Fahrenheit, - 09/14/20 at 7:54 P.M., temperature of 99.2 degrees Fahrenheit, - 09/24/20 at 10:34 A.M., temperature of 99.3 degrees Fahrenheit, - 10/01/20 at 7:23 P.M., temperature of 99.1 degrees Fahrenheit, - 10/02/20 at 7:28 A.M., temperature of 99.1 degrees Fahrenheit, - 10/03/20 at 9:02 P.M., temperature of 99.3 degrees Fahrenheit, - 10/07/20 at 3:09 P.M., temperature of 99.7 degrees Fahrenheit, - 10/07/20 at 6:55 P.M., temperature of 99.7 degrees Fahrenheit, - 10/08/20 at 8:01 A.M., temperature of 99.8 degrees Fahrenheit, There were no progress notes in the resident's clinical record regarding the resident's elevated temperatures. There was no indication in the resident's clinical record that the resident was in any type of isolation. During an observation on 10/09/20 at 3:48 P.M., Resident F was in her room with a roommate, Resident E. There was no indication the residents were in isolation. During an interview on 10/09/20 at 3:48 P.M., CRMA (Certified Residential Medication Aide) 3 indicated that she had not worked since the previous weekend. She was not notified in report today of any residents that resided on the 100 hall that had recently experienced a fever. There were no residents on the 100 hall in isolation. During an interview with the DON and Administrator on 10/09/20 at 4:51 P.M., the DON indicated the facility consulted the Nurse Practitioner, and the Nurse Practitioner did not consider Resident F's temperatures as fever. It was not considered a fever until the temperature was 100.4 F. When asked about CDC (Centers for Disease Control) guidance related to what would be considered a fever, the Administrator indicated the facility would follow the Nurse Practitioner's guidance related to what would constitute a fever. The LTC (Long Term Care) Respiratory Surveillance Line List the facility currently utilized for data collection and active monitoring of both residents and staff indicated, .Definition of Fever .(1) a single oral temp > 37.8 (degrees) C (100 F) or (2) repeated oral temps > 37.2 C (99 F) or rectal temps > 37.5 C (99.5 F) or (3) a single temp > 1.1 C (2 F) over baseline from any site (oral, tympanic, axillary) . The current facility policy, titled Guidelines for Covid-19 Standard of Practice, with a most recent revision date on 03/11/20, was provided by the DON on 10/09/20 at 2:51 P.M. The policy indicated, .Evaluate and Manage Residents with Symptoms of Respiratory Infection .Promptly assess residents for fever and symptoms and signs of respiratory infection .Implement appropriate infection prevention practices for symptomatic residents .Isolation precautions should be made on a case-by-case basis and in consultation with public health officials . The CDC guidance - Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, dated as updated 6/25/20, indicated the following: Evaluate and Manage Residents with Symptoms of COVID-19. Ask residents to report if they feel feverish or have symptoms consistent with COVID-19. Actively monitor all residents upon admission and at least daily for fever (T greater than or equal to 100.0 F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below. Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0 F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19. Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility with dedicated HCP (see section on Dedicating Space). As roommates of residents with COVID-19 might already be exposed, it is generally not recommended to place them with another roommate until 14 days after their exposure, assuming they have not developed symptoms or had a positive test. Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn when PPE is indicated. The Immediate Jeopardy that began on 10/02/20 was removed on 10/10/20 at 2:46 P.M., when the facility audited all residents in the facility for new onset of COVID-19 symptoms with any residents showing symptoms of COVID-19 had been placed on contact/droplet precautions, and all staff were inserviced/educated on signs and symptoms of COVID-19 and contact/droplet precautions. 3.1-18(a)

Based on interview and record review, the facility failed to ensure a resident's (Resident B) code status was accurately documented in the medical record and to ensure a resident's wishes (Advance Directives) to not be resuscitated were followed, which resulted in a resident receiving life saving measures when respirations and pulse ceased, including the administration of intraosseous (medication received through an IV via vein) medications and mechanical ventilation. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 3:30 p.m. when staff initiated Cardiopulmonary Resuscitation (CPR) on a resident (Resident B) with an active DNR (Do Not Resuscitate) status. The Executive Director, Director of Health Services, and Clinical Support were notified of the Immediate Jeopardy on [DATE] at 1:04 p.m. Findings include: The clinical record for Resident B was reviewed on [DATE] at 10:35 a.m. [DIAGNOSES REDACTED]. The Out of Hospital Do Not Resuscitate Declaration and Order, dated [DATE], indicated if the resident experienced cardiac or [MEDICAL CONDITION] failure in a location other than an acute care hospital, cardiopulmonary resuscitation procedures were to be withheld, the resident be permitted to die naturally, and that medical care included any medical procedure necessary to provide comfort or alleviate pain. The document was signed by the physician on [DATE]. The hospital note, dated [DATE] at 11:34 a.m., indicated the resident had power of attorney documents and had made it known that she had wish to be a DO NOT RESUSCITATE. The readmission order, dated [DATE], indicated the resident was to be a DNR. The resident's current Face Sheet indicated the resident was a full code (CPR). The CPR consent, attached to the resident's medical record on [DATE], indicated NO CPR and was signed by the resident. During an interview, on [DATE] at 1:02 p.m., Family Member 7 indicated when Resident B was in the hospital on [DATE], Hospitalist 6 came into her room and spoke extensively to the resident about her code status and she told him she did not want CPR or to be put on a ventilator. On [DATE] at 10:58 a.m., during an interview with Hospitalist 6, he indicated when Resident B was admitted on [DATE] he spoke extensively with the resident with regards to her decline in health as well as her advance directives and the resident was adamant that she did not want CPR or to be put on a ventilator. The progress note, dated [DATE] at 3:57 p.m., indicated the DHS (Director of Health Services) entered Resident B's room at 3:28 p.m. The resident was cyanotic (blue skin) and stated please help me. I can't breathe. The resident was wearing oxygen upon entering the room and the resident's [MEDICAL CONDITION] was applied with oxygen saturation of 44% (percent). The resident became unresponsive and was pulled to the floor. The defibrillator was applied to the chest and no shocks given. CPR was initiated, EMS (emergency medical services) took over care, and the resident's first contact was notified. The progress note, dated [DATE] at 4:19 p.m., indicated staff summoned for help at approximately 3:30 p.m. The resident was found up in her wheel chair with labored respirations, nasal cannula in place, and the resident stated please help, I can't breathe. Her [MEDICAL CONDITION] was immediately placed. Initial assessment indicated oxygen saturation of 44%. Resident was observed to have agonal (gasping) respirations, cyanotic in color, and no pulse detected. CPR was initiated an AED (automated external defibrillator) was placed on the resident with no shocks advised. The resident remained pulseless. CPR and rescue breathing continued until EMS arrived and resident care transferred to EMS. The progress note, dated [DATE] at 5:33 p.m., indicated the writer entered the room and noticed the resident was in distress. The resident stated Get me some oxygen. The resident already had a concentrator in room for the [MEDICAL CONDITION] used at night. The writer ran to the supply room to get a nasal cannula and oxygen was initiated. The resident became more distressed. The resident stated please help me, and the oxygen saturation was 44%. The [MEDICAL CONDITION] was applied and the oxygen saturation went to 77%. The resident was placed on the floor. CPR was initiated until EMS arrived and took over resident care. During an interview, on [DATE] at 11:55 a.m., the DHS (Director of Health Services) indicated the medical records nurse discontinued the DNR order and entered the full code order on [DATE]. During an interview, on [DATE] at 11:58 a.m., MR (Medical Records) 4 indicated the CPR sheets were new and when she saw the CPR at the top of the sheet she thought it was for a full code. During an interview, on [DATE] at 1:03 p.m., the DHS indicated the POST form for the resident carried over to the healthcare side, since they are linked, which was signed by the physician. During an interview, on [DATE] at 2:18 p.m., LPN (Licensed Practical Nurse) 5 indicated the resident's call light was on and when she entered the resident's room, the resident told her she needed more oxygen. LPN 5 went to the supply to retrieve a nasal cannula and put it on her. She became more distressed and requested help. The resident kept saying please help me, please help me. After the [MEDICAL CONDITION] was placed, the resident went limp, she was not breathing, was completely blue, and had no pulse. CPR was initiated and EMS took over care upon arrival. During an interview, on [DATE] at 2:33 p.m., the ADHS (Assistant Director of Health Services) indicated they were summoned to the resident's room. When she entered Resident B's room, the resident had a nasal cannula in place. The resident kept stating over and over help me, help me, I can't breathe, help me. They managed to get the [MEDICAL CONDITION] on her, she continued to struggle, and was declining rapidly. After the resident was put on the floor, there was no pulse or respirations, and CPR was initiated until EMS arrived and took over care. During an interview, on [DATE] at 2:43 p.m., the DHS indicated when she entered the room the resident had oxygen on and called her and the Administrator by name asking for help. Her oxygen saturation was at 44% and I placed the [MEDICAL CONDITION] on her, at which time her saturation increased to 77%. All of the sudden she went limp, she became unresponsive, and the resident was pulled to the floor. She had no pulse or respirations and CPR was initiated until EMS arrived. The General Power of Attorney, dated [DATE], included, but was not limited to, I, (Resident B's name) .do hereby appoint .as my attorney-in-fact for me and in my name to .Health Care .Act as my representative in matters affecting my health care whenever I am incapable of consenting to my own health care .Remove or Withhold Treatment .I authorize my health care representative to make decisions in my best interest concerning withdrawal or withholding of health care. If at any time, based upon my previously expressed preferences and physician's [DIAGNOSES REDACTED].then my health care representative may express my will that such health care be withheld or withdrawn and may consent on my behalf that any or all health care be discontinued or not instituted, even if death may result. This power includes, but is not limited to, requesting that the following be discontinued or not instituted .cardiopulmonary resuscitation .My health care representative must try to discuss this decision with me. However, if I am unable to communicate, my health care representative may make such a decision for me, after consultation with my physician or physicians and other relevant health care givers The clinical record lacked documentation of the resident verbally revoking the DNR status, physician and family consent to initiate CPR. The EMS report, dated [DATE], indicated EMS was dispatched to the facility for a resident in respiratory distress then told [MEDICAL CONDITION]. The patient was found on the floor with staff performing CPR. Staff had been working on the resident for five minutes. The resident had no pulse and no breathing. During CPR the resident regained agonal breathing, a gag reflex, and a pulse of 120 beats per minute, her color was pale with no movement of the extremities, and resident moaned occasionally. IVF (intravenous fluids) were administered of NaCl (sodium chloride) at KVO (keep vein open). During an interview, on [DATE] at 2:01 p.m., EMS 2 indicated when first on scene staff were performing CPR. The resident was unresponsive with no pulse or respirations. The resident was given [MEDICATION NAME] per IV and a pulse was observed. We tried to get paperwork but they had printed off paperwork for a different resident. We were told by facility staff the resident was a full code. The staff never told us the resident had asked for help or was a DNR, and, had we known, we would have called the ER (emergency room ) physician to get direction and would more than likely told us not to do CPR. During an interview, on [DATE] at 2:31 p.m., EMS 3 indicated when first on scene staff were performing CPR due to no pulse or respirations. I specifically asked if the resident was a full code and the nurse told me as far as she knew. EMS 3 did not recall the nurses name. The hospital discharge summary, dated [DATE], indicated EMS arrived to the facility to find the resident pulseless. There was an apparent confusion in documents, and it was believed that the patient was a full code and not a DNR (she was designated Do Not Resuscitate). The patient subsequently received CPR and subsequent intubation upon arrival to the ED (emergency department). The patient was extubated and passed at 8:51 p.m. On [DATE] at 11:08 a.m., the DHS provided a current copy of the document titled Guidelines for Advanced Directives dated [DATE]. It included, but was not limited to, Purpose .To ensure facility staff .follows resident's advanced directives regarding end of life care .2. The resident or representative will advise .regarding wished for end of life directives and code status. The DNR form will be completed documenting these desires and placed in the medical record On [DATE] at 11:08 a.m., the Administrator provided a current copy of the document titled Guidelines for DNR Orders dated [DATE]. It included, but was not limited to, Purpose .To ensure residents wishes to not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect is followed .3. Should a resident be transferred to the hospital, a photocopy or original copy of the DNR shall be provided to the EMT personnel transporting the resident to the hospital On [DATE] at 2:48 p.m., the Administrator provided a current copy of the document titled Cardiopulmonary Resuscitation (CPR), dated [DATE]. It included, but was not limited to, Purpose .To provide guidelines for the administration of cardiopulmonary resuscitation .1. The resident's code status should be determined at admission .4. If the resident has Do Not Resuscitate orders signed by the physician, no CPR is expected The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility completed staff education on following resident wishes related to code status, placing the code status on the face sheet as ordered by the physician and ensure that the code status form reflects information listed on physician orders, and in the event that a resident that has previously signed a DNR, unless the resident or POA (power of attorney) specifically states they want to change their code status, the resident's wishes will be honored. The Immediate Jeopardy was removed on [DATE] but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff had been educated on in the event that a resident that has previously signed a DNR, unless the resident or POA (power of attorney) specifically states they want to change their code status, the resident's wishes will be honored. This Federal tag relates to Complaint IN 238 3XXX,[DATE](4)(B)(7)

Based on record review and interview, the facility failed to accurately assess, document and notify the physician of changes related to a resident's wound dehiscence (surgical complication in which a wound ruptures along a surgical incision), which resulted in harm in that the resident experienced two accidents (during an improper transfer and fall), which resulted in a total wound dehiscence and new quadriceps tendon rupture of a previously approximated total right knee arthroplasty (Resident B). Findings include: Resident B's closed clinical record was reviewed on 5/4/2016 at 10:45 a.m. [DIAGNOSES REDACTED]. The resident was admitted to the facility, on 3/26/2016, for aftercare following an elective right knee total arthroplasty (orthopedic surgical procedure where the articular surface of a musculoskeletal joint is replaced) performed on 3/22/2016. Admission Minimum Data Set (MDS) assessment, dated 4/2/2016, indicated a Brief Interview for Mental Status of 15 of 15; indicating the resident was cognitively intact. The resident required extensive, 2+ physical assist for transfers and toileting. physician's orders [REDACTED]. Change [MEDICATION NAME] island dressing to right knee .once a day. D/C (discontinue date): 4/7/2016 . A Care Plan for Resident B, initiated 4/5/2016, indicated, Problem: Resident has surgical wound to right knee following a right TKR (total knee replacement) .Approach: .Record the amount, type, consistency, color, and odor of drainage from the wound if any .Report complications (e.g., .hemorrhage .dehiscence . A Care Plan for Resident B, initiated 4/5/2016, indicated, Problem: My ability to transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene, has deteriorated R/T Right total knee replacement .Approach: .Provide extensive assist for ADL's (activities of daily living) . A Care Plan for Resident B, initiated 4/6/2016, indicated, Problem: I am at risk for falling R/T (related to) medication usage with side effects, and decreased mobility related to Right knee replacement .Approach: .I require assist with transfers . Resident B's Orthopedic Follow-Up, dated 4/6/2016, indicated, .Site: knee. Exam Site: Right. Exam: Clean, dry, intact, no [DIAGNOSES REDACTED] (redness), no purulence, no s/s infection .Patient is doing well .The wound looks good today. A Skin Integrity Even for Resident B, dated 3/26/2016, indicated, .1. Incision present on admission? Yes. 2. Describe location of incision: rt (right) knee. 3. Length (cm) (centimeter): Head to Toe (12 to 6 o'clock): 19 cm. 4. Width (cm): Side to Side (3 to 9 o'clock): 0 cm. 5. Depth (cm): 0 cm. Exudate (fluid from a wound): No exudate. Wound Edges: Smooth. Well-approximated. Wound approximated with? Dermabond .Section 2: Incision Documentation (ongoing up to 10 weeks): Re-assessment/measurement 1: Date: 3/28/2016: Incision length: 19 cm. Incision depth: 0 cm. Incision width: 0 cm. No exudate noted. Re-assessment/measurement 1: Date: 4/4/2016: Incision length: 19 cm. Incision depth: 0 cm. Incision width: 0 cm. No exudate noted The completed/closed date indicated 4/9/2016. Re-assessment/measurements for weeks three through 10 were blank. There was no evidence of additional documentation of wound measurements until the following Skin Integrity Report, dated 4/13/2016. Resident Progress Notes, dated 4/11/2016 at 9:18 p.m., indicated, Resident picking at knee wound, causing bleeding; covered with [MEDICATION NAME] island dressing to protect at this time. Resident Progress Notes, dated 4/12/2016 at 9:30 a.m. (recorded as late entry 4/13/2016 at 11:40 a.m.), indicated, (Surgeon) office notified of rt (right) knee bleeding in middle of incision line. No s/s (signs or symptoms of) infection noted . Resident Progress Notes, dated 4/12/2016 at 3:56 p.m., indicated, Call from (surgeon) office that resident needs to be seen tomorrow at 10 a.m . Physical Therapy (PT) Daily Treatment Note, dated 4/12/2016 (no time), indicated, Pt (patient) this am (sic) came to therapy with dressing on his R TKR (total knee replacement) site had blood saturated. Nursing notes she had just dressed his knee and again redressed the knee. Pt had an open area on his R (right) incision site that was draining blood. Pt notes that when he was transferring to the toilet last night he felt a 'twinge like I had been shot by a bullet' . Resident Progress Notes, dated 4/13/2016 at 1:15 a.m., indicated, CNA (Certified Nursing Assistant) came and got this nurse. Resident laying on back next to bed. Alert and oriented x 3 .Resident stated he rolled over and slid out of bed. Assessed resident he was able to move all extremities. Denies pain or discomfort. 3 people to assist back in bed .(Spouse) and (primary physician) notified. Resident B's Skin Integrity Report, dated 4/13/2016 at 8:30 a.m., indicated, .Description: Rt (right) knee surgical incision dehiscance (sic) .3. Length (cm) (centimeter): Head to Toe (12 to 6 o'clock): 13 cm. 4. Width (cm): Side to Side (3 to 9 o'clock): 1.5 cm. 5. Depth (cm) .: res (resident) to see surgeon this am, signee not comfortable disturbing wound/risk of increased bleeding The Skin Integrity Report did not indicate a mechanism of injury, cause for dehiscence, or any previous wound concerns. The following Resident Progress Notes, dated 4/13/2016 at 8:34 a.m., indicated, .pressure dressing applied to RT knee to aid in reducing bleeding et to keep covered to reduce risk of infection to dehisced rt tkr. edges of wound open 1.5 cm wide. Resident Progress Notes, dated 4/13/2016 at 9:32 a.m., indicated, Res follow up fall with no injuries noted. Res ate breakfast in bed this am d/t incision complications . Orthopedic Operative Note, dated 4/13/16 at 7:12 p.m., indicated, Preoperative Diagnosis: [REDACTED]. Postoperative Diagnoses: [REDACTED]. 2. Quadriceps tendon rupture. Procedure: Right knee incision and drainage with polyethylene exchange and quadriceps tendon repair and wound closure .Indication for Procedure: .status [REDACTED].It should be noted that the quadriceps tendon was completely avulsed off the superior aspect of the patella (knee bone) and there was a partial arthrotomy (creation of an opening in a joint that may be used in drainage) rupture distally .debride the knee of soft tissue debris .placed a new .polyethylene liner (plastic portion of artificial knee joint) into place. I repaired the arthrotomy rupture . Resident B's Hospital Consultation Report, dictated by his primary care physician and dated 4/15/2016, indicated, .Apparently on the early morning hours of the date of his presentation to (surgeon's office) on the 13th, he had a fall out of bed .The fall was not reported to my (sic) by the skilled nursing facility and did not learn on that until (surgeon) called me . The Physical Therapy Director was interviewed on 5/4/2016 at 2:38 p.m. She indicated she saw Resident B just after breakfast and before therapy on 4/12/2016. She indicated Resident B described having right knee pain following being assisted to the bathroom [ROOM NUMBER]/11/2016. She indicated that Resident B described a twinge and that it felt like a bullet when he transferred to the commode. Resident B's Orthopaedic Surgeon was interviewed on 5/5/2016 at 11:44 a.m. He indicated, We got conflicting stories (from the facility). Initially they said he had a little wound issue because he was picking at his wound or he might have bumped it at night. They didn't tell us he fell .even after he showed up here. They kept saying he may have bumped his knee. His knee was completely busted open. There is no way picking at it or bumping it would have gotten it to that level .The amount of damage done .his knee would have had to buckle underneath him .be hyperflexed. (Resident B) ruptured the native tendon under his knee cap. It was more violent than they described .more violent than rolling out of bed .No way that happened on transport (from facility to appointment). It had to be a violent fall. The blood on the dressing was coagulated so it wasn't acute . The surgeon described the right knee wound as seven inches long, full thickness, down to the bone and metal implant. The Orthopeadic Surgeon's X-Ray Technician and Assistant was interviewed on 5/5/2016 at 11:52 a.m. She indicated she received a call on the facility 5/12/2016 and indicated, They felt like he may have bumped his knee through the night and it was bleeding pretty good, but made it seem like it wasn't a big issue. When the surgeon's assistant called the facility to relay that the surgeon wanted to see the resident the following day, the assistant indicated, The nurse said, 'Well I don't know why they told you he bumped it. He's picking it open.' The assistant indicated, When the resident turned up (for scheduled appointment on 4/13/2016 at 10 a.m.) we were in total shock (at the knee). Nobody reported the fall. They stuck with the story that he may have bumped his knee until the doc called and said, 'There's no way.' Finally they said that he fell . On 5/5/2016 at 10:20 a.m., the Director of Nursing Services (DNS) indicated there was no fall event or fall investigation related to Resident B's documented fall on 4/13/2016 at 1:15 a.m. Resident B's son was interviewed on 5/5/2016 at 10:44 a.m. He indicated he visited his father almost daily after work and would arrive at the facility between 6:30 p.m. and 7:00 p.m. Resident B's son indicated when he arrived on 4/11/2016, his fathers sheets were saturated with blood .looked like it was watered down, like with drainage. The son indicated there was a scabbed area (on the resident's right knee) leaking fluid. He described the fluid as running down his (Resident B's leg) .it just kept streaming down his leg and I kept wiping it .I brought it to her (nurse on duty) attention and she just didn't seem to care. Resident B's son described the drainage as saturating a two-foot area on the sheets. Resident B's son indicated the nurse on duty indicated to him Resident B had been picking at his knee. The right knee was not covered with any dressing or bandage and the sheets were not changed during the two hours Resident B's son was there. Resident B's son indicated he did not see his father picking at his knee and his father denied picking at his knee. Resident B's son indicated his father told him on 4/13/2016 about an incident on the commode which occurred on 4/11/2016. He indicated, My dad told me he was in the bathroom .and she (staff assisting him) was rough. She told him, 'You need to work.' Then she twisted him and when she did, he (Resident B) said, 'It (right knee) popped and I screamed.' He said something about a 'twinge.' He said the nurse said, 'If something was really wrong, you'd scream a lot louder than that.' Resident B's son indicated he was the Power of Attorney and first contact for his father. The facility did not notify him at any time of the wound dehiscence and did not notify him that his father had fallen. Resident B's son indicated he was not notified of his father's fall until he received a call from his mother around 6:30 a.m. on 4/13/2016 and she reported to him that the facility had just called her and indicated he had fallen and there was a one inch dash in his knee where it was leaking and separated. Resident B's son indicated he met Resident B at the Surgeon's office for his scheduled 10:00 a.m. appointment on 4/13/2016. He indicated, When the doc opened the bandage, we were all in shock. It was ten to twelve inches long and completely open. I could see the metal implant. (Surgeon) said the tendon was torn from the top of his knee cap. On 5/5/2016 at 4:10 p.m., the Executive Director (ED) indicated the nurse did not check Resident B's surgical wound after the fall, but should have. He indicated a Fall Event Form and/or Change in Condition Form were not initiated, and the surgeon was not notified of the fall because the resident had an appointment to see the physician later that day. Resident B was interviewed on 5/6/2016 at 10:10 a.m. via phone. The resident indicated one person frequently assisted him to the bathroom and indicated, It was hard to get that many together. Every once in a while it would take quite a while to get just one. Resident B indicated he could not recall who assisted him with toileting on 4/11/2016, but did remember that it was one person. Resident B indicated, I was taking therapy. I needed to go to the restroom .needed to get on the commode and she said, 'You're gonna (sic) have to help me more than you are' and I said, 'I can't.' She put her hands on my shoulder and spun me around and put me on the commode. I hollered (sic) because it hurt bad. It done something wrong. She said, 'If it was really hurt, you'd have yelled louder than that.' Resident B indicated he could not recall dates, but did recall blood on his his sheets. The resident indicated, There was quite a bit of blood on them (sheets). (They were) soaked all the way through and dripping. The resident indicated, They (facility staff) were aware of that, but not too concerned. Resident B indicated he did not recall picking at his knee. On 5/6/2016 at 12:46 p.m., the DNS indicated she was not aware of the incident on the commode on 4/11/2016 until 5/4/2016 when she reviewed the PT note. On 5/6/2016 at 12:46 p.m., the ED and DNS were interviewed. The ED indicated, We thought the dehiscence wasn't related to the fall. It (dehiscence) was an underlying issue. I think if he hadn't fallen that night, that wound still would have opened up. The DNS indicated, Me too. A copy of the current Falls Management Program Guidelines Policy and Procedure was provided by the ED on 5/4/2016 at 4:12 p.m. The procedure indicated, .3. Should the resident experience a fall the attending nurse shall complete the 'Fall Circumstance and Reassessment Form' .4. The staff member attending to the resident at the time of the incident should notify the attending physician or medical director . A copy of the current Change in Condition Form Guidelines Policy and Procedure was provided by the ED on 5/5/2016 at 3:45 p.m. The purpose indicated, To facilitate the thorough and consistent review and completion of the nursing process .documents the change in resident status, care plan update and notification of change. Procedure: 1. Upon assessment of a resident change in status, the nurse shall initiate the Condition Change Form in order to fully reflect and document the nursing process .3. The nurse will notify the physician . These Federal and State tags are related to Complaint IN 124. 3.1-37(a)

Based on record review and interview, the facility failed to notify the physician of changes related to one resident who sustained a fall which resulted in a total wound dehiscence (surgical complication in which a wound ruptures along a surgical incision) and new quadriceps tendon rupture of a previously approximated total right knee arthroplasty (Resident B). Findings include: Resident B's closed clinical record was reviewed on 5/4/2016 at 10:45 a.m. [DIAGNOSES REDACTED]. The resident was admitted to the facility, on 3/26/2016, for aftercare following an elective right knee total arthroplasty (orthopedic surgical procedure where the articular surface of a musculoskeletal joint is replaced) performed on 3/22/2016. Admission Minimum Data Set (MDS) assessment, dated 4/2/2016, indicated a Brief Interview for Mental Status of 15 out of 15; indicating the resident was cognitively intact. The resident required extensive, 2+ physical assist for transfers and toileting. A Care Plan for Resident B, initiated 4/5/2016, indicated, Problem: Resident has surgical wound to right knee following a right TKR (total knee replacement) .Approach: .Record the amount, type, consistency, color, and odor of drainage from the wound if any .Report complications (e.g., .hemorrhage .dehiscence . Resident B's Orthopedic Follow-Up, dated 4/6/2016, indicated, .Site: knee. Exam Site: Right. Exam: Clean, dry, intact, no [DIAGNOSES REDACTED] (redness), no purulence, no s/s infection Patient is doing well .The wound looks good today. A Skin Integrity Event for Resident B, dated 3/26/2016, indicated, .1. Incision present on admission? Yes. 2. Describe location of incision: rt (right) knee. 3. Length (cm) (centimeter): Head to Toe (12 to 6 o'clock): 19 cm. 4. Width (cm): Side to Side (3 to 9 o'clock): 0 cm. 5. Depth (cm): 0 cm. Exudate (fluid from a wound): No exudate. Wound Edges: Smooth. Well-approximated. Wound approximated with? Dermabond .Section 2: Incision Documentation (ongoing up to 10 weeks): Re-assessment/measurement 1: Date: 3/28/2016: Incision length: 19 cm. Incision depth: 0 cm. Incision width: 0 cm. No exudate noted. Re-assessment/measurement 1: Date: 4/4/2016: Incision length: 19 cm. Incision depth: 0 cm. Incision width: 0 cm. No exudate noted . Re-assessment/measurements for weeks three through 10 were blank. There was no evidence of additional documentation of wound measurements until the following Skin Integrity Report, dated 4/13/2016. Resident Progress Notes, dated 4/11/2016 at 9:18 p.m., indicated, Resident picking at knee wound, causing bleeding; covered with [MEDICATION NAME] island dressing to protect at this time. Resident Progress Notes, dated 4/12/2016 at 9:30 a.m. (recorded as late entry 4/13/2016 at 11:40 a.m.), indicated, (Surgeon) office notified of rt (right) knee bleeding in middle of incision line. No s/s (signs or symptoms of) infection noted . Resident Progress Notes, dated 4/12/2016 at 3:56 p.m., indicated, Call from (surgeon) office that resident needs to be seen tomorrow at 10 a.m . Physical Therapy Daily Treatment Note, dated 4/12/2016 (no time), indicated, Pt (patient) this am (sic) came to therapy with dressing on his R TKR (total knee replacement) site had blood saturated. Nursing notes she had just dressed his knee and again redressed the knee. Pt had an open area on his R (right) incision site that was draining blood. Pt notes that when he was transferring to the toilet last night he felt a 'twinge like I had been shot by a bullet' . Resident Progress Notes, dated 4/13/2016 at 1:15 a.m., indicated, CNA (Certified Nursing Assistant) came and got this nurse. Resident laying on back next to bed. Alert and oriented x 3 .Resident stated he rolled over and slid out of bed. Assessed resident he was able to move all extremities. Denies pain or discomfort. 3 people to assist back in bed .(Spouse) and (primary physician) notified. Resident B's Skin Integrity Report, dated 4/13/2016 at 8:30 a.m., indicated, .Description: Rt (right) knee surgical incision dehiscance (sic) .3. Length (cm) (centimeter): Head to Toe (12 to 6 o'clock): 13 cm. 4. Width (cm): Side to Side (3 to 9 o'clock): 1.5 cm. 5. Depth (cm) . res (resident) to see surgeon this am, signee not comfortable disturbing wound/risk of increased bleeding . The Skin Integrity Report did not indicate a mechanism of injury, cause for dehiscence, or any previous wound concerns. The following Resident Progress Notes, dated 4/13/2016 at 8:34 a.m., indicated, .pressure dressing applied to RT knee to aid in reducing bleeding et (and) to keep covered to reduce risk of infection to dehisced rt tkr. edges of wound open 1.5 cm wide. Resident Progress Notes, dated 4/13/2016 at 9:32 a.m., indicated, Res follow up fall with no injuries noted. Res ate breakfast in bed this am d/t (due to) incision complications . Orthopedic Operative Note, dated 4/13/16 at 7:12 p.m., indicated, Preoperative Diagnosis: [REDACTED]. Postoperative Diagnoses: [REDACTED]. 2. Quadriceps tendon rupture. Procedure: Right knee incision and drainage with polyethylene exchange and quadriceps tendon repair and wound closure .Indication for Procedure: .status [REDACTED].It should be noted that the quadriceps tendon was completely avulsed off the superior aspect of the patella (knee bone) and there was a partial arthrotomy (creation of an opening in a joint that may be used in drainage) rupture distally .debride the knee of soft tissue debris .placed a new .polyethylene liner (plastic portion of artificial knee joint) into place. I repaired the arthrotomy rupture . Resident B's Hospital Consultation Report, dictated by his primary care physician and dated 4/15/2016, indicated, .Apparently on the early morning hours of the date of his presentation to (surgeon's office) on the 13th, he had a fall out of bed .The fall was not reported to my (sic) by the skilled nursing facility and did not learn on that until (surgeon) called me . The Physical Therapy (PT) Director was interviewed on 5/4/2016 at 2:38 p.m. She indicated she saw Resident B just after breakfast and before therapy on 4/12/2016. She indicated Resident B described having right knee pain following being assisted to the bathroom [ROOM NUMBER]/11/2016. She indicated that Resident B described a twinge and that it felt like a bullet when he transferred to the commode. Resident B's Orthopaedic Surgeon was interviewed on 5/5/2016 at 11:44 a.m. He indicated, We got conflicting stories (from the facility). Initially they said he had a little wound issue because he was picking at his wound or he might have bumped it at night. They didn't tell us he fell .even after he showed up here. They kept saying he may have bumped his knee. His knee was completely busted open. There is no way picking at it or bumping it would have gotten it to that level .The amount of damage done .his knee would have had to buckle underneath him .be hyperflexed. (Resident B) ruptured the native tendon under his knee cap. It was more violent than they described .more violent than rolling out of bed .No way that happened on transport (from facility to appointment). It had to be a violent fall. The blood on the dressing was coagulated so it wasn't acute The surgeon described the right knee wound as seven inches long, full thickness, down to the bone and metal implant. The Orthopaedic Surgeon's X-Ray Technician and Assistant was interviewed on 5/5/2016 at 11:52 a.m. She indicated she received a call on the facility 5/12/2016 and indicated, They felt like he may have bumped his knee through the night and it was bleeding pretty good, but made it seem like it wasn't a big issue. When the surgeon's assistant called the facility to relay that the surgeon wanted to see the resident the following day, the assistant indicated, The nurse said, 'Well I don't know why they told you he bumped it. He's picking it open.' The assistant indicated, When the resident turned up (for scheduled appointment on 4/13/2016 at 10 a.m.) we were in total shock (at the knee). Nobody reported the fall. They stuck with the story that he may have bumped his knee until the doc called and said, 'There's no way.' Finally they said that he fell . On 5/5/2016 at 10:20 a.m., the Director of Nursing Services (DNS) indicated there was no fall event or fall investigation related to Resident B's documented fall on 4/13/2016 at 1:15 a.m. Resident B's son was interviewed on 5/5/2016 at 10:44 a.m. He indicated he visited his father almost daily after work and would arrive at the facility between 6:30 p.m. and 7:00 p.m. Resident B's son indicated when he arrived on 4/11/2016, his fathers sheets were saturated with blood .looked like it was watered down, like with drainage. The son indicated there was a scabbed area (on the resident's right knee) leaking fluid. He described the fluid as running down his (Resident B's leg) .it just kept streaming down his leg and I kept wiping it .I brought it to her (nurse on duty) attention and she just didn't seem to care. Resident B's son described the drainage as saturating a two-foot area on the sheets. Resident B's son indicated the nurse on duty indicated to him Resident B had been picking at his knee. The right knee was not covered with any dressing or bandage and the sheets were not changed during the two hours Resident B's son was there. Resident B's son indicated he did not see his father picking at his knee and his father denied picking at his knee. Resident B's son indicated his father told him on 4/13/2016 about an incident on the commode which occurred on 4/11/2016. He indicated, My dad told me he was in the bathroom .and she (staff assisting him) was rough. She told him, 'You need to work.' Then she twisted him and when she did, he (Resident B) said, 'It (right knee) popped and I screamed.' He said something about a 'twinge.' He said the nurse said, 'If something was really wrong, you'd scream a lot louder than that.' Resident B's son indicated he was the Power of Attorney and first contact for his father. The facility did not notify him at any time of the wound dehiscence and did not notify him that his father had fallen. Resident B's son indicated he was not notified of his father's fall until he received a call from his mother around 6:30 a.m. on 4/13/2016 and she reported to him that the facility had just called her and indicated he had fallen and there was a one inch dash in his knee where it was leaking and separated. Resident B's son indicated he met Resident B at the Surgeon's office for his scheduled 10:00 a.m. appointment on 4/13/2016. He indicated, When the doc opened the bandage, we were all in shock. It was ten to twelve inches long and completely open. I could see the metal implant. (Surgeon) said the tendon was torn from the top of his knee cap. On 5/5/2016 at 3:28 p.m., the DNS indicated, I would expect they (nursing staff) would send that information (regarding fall) with him to the appointment. On 5/5/2016 at 4:10 p.m., the Executive Director (ED) indicated the nurse did not check Resident B's surgical wound after the fall, but should have. Resident B was interviewed on 5/6/2016 at 10:10 a.m. via phone. The resident indicated one person frequently assisted him to the bathroom and indicated, It was hard to get that many together. Every once in a while it would take quite a while to get just one. Resident B indicated he could not recall who assisted him with toileting on 4/11/2016, but did remember that it was one person. Resident B indicated, I was taking therapy. I needed to go to the restroom .needed to get on the commode and she said, 'You're gonna (sic) have to help me more than you are' and I said, 'I can't.' She put her hands on my shoulder and spun me around and put me on the commode. I hollered (sic) because it hurt bad. It done something wrong. She said, 'If it was really hurt, you'd have yelled louder than that.' Resident B indicated he could not recall dates, but did recall blood on his his sheets. The resident indicated, There was quite a bit of blood on them (sheets). (They were) soaked all the way through and dripping. The resident indicated, They (facility staff) were aware of that, but not too concerned. Resident B indicated he did not recall picking at his knee. On 5/6/2016 at 12:46 p.m., the DNS indicated she was not aware of the incident on the commode on 4/11/2016 until 5/4/2016 when she reviewed the PT note. On 5/6/2016 at 12:46 p.m., the ED and DNS were interviewed. The ED indicated, We thought the dehiscence wasn't related to the fall. It (dehiscence) was an underlying issue. I think if he hadn't fallen that night, that wound still would have opened up. The DNS indicated, Me too. A copy of the current Falls Management Program Guidelines Policy and Procedure was provided by the ED on 5/4/2016 at 4:12 p.m. The procedure indicated, .3. Should the resident experience a fall the attending nurse shall complete the 'Fall Circumstance and Reassessment Form' .4. The staff member attending to the resident at the time of the incident should notify the attending physician or medical director . A copy of the current Change in Condition Form Guidelines Policy and Procedure was provided by the ED on 5/5/2016 at 3:45 p.m. The purpose indicated, To facilitate the thorough and consistent review and completion of the nursing process .documents the change in resident status, care plan update and notification of change. Procedure: 1. Upon assessment of a resident change in status, the nurse shall initiate the Condition Change Form in order to fully reflect and document the nursing process .3. The nurse will notify the physician . A copy of the current Physician Notification Guidelines Policy and Procedure was provided by the DNS on 5/5/2016 at 3:45 p.m. The purpose indicated, To ensure the resident's physician is aware of all .change in condition in a timely manner .1. Resident assessments for change in condition, suspected injury, event of unknown origin .should be completed in a timely manner. 2. The physician should be notified of .an immediate need by phone as soon as the results are known . These Federal and State tags are related to Complaint IN 124. 3.1-5(a)(1) 3.1-5(a)(2)